Cerebral Protection Devices during Transcatheter Interventions: Indications, Benefits, and Limitations

Neuroprotection Devices in Cardiac Catheterization Laboratories: Does It Sufficiently Protect Our Patients?

Stroke is a devastating complication of cardiovascular interventions. Intraprocedural stroke is a well-documented and feared risk of cardiac percutaneous transcatheter procedures. If clinically significant strokes are absent, silent strokes remain the next in line to pose large concerns related to future cognitive decline, stroke risk, and overall increased morbidity and mortality. Cerebral protection devices (CPD) developed overtime aim to neutralize this risk through either a capture-based filter or a deflector mechanism. Many CPDs exist currently, each one unique, with varying degrees of evidence. The adoption of CPDs has allowed cardiac percutaneous transcatheter procedures to be carried out in patients with high thromboembolic risks who may have historically been discommended. Though skewed towards certain devices and transcatheter procedures, a large body of evidence is still present across other devices and procedures. This review will discuss clinical importance and respective stroke rates, updated evidence surrounding CPDs, differing opinions across types of CPDs, cost benefits, and what lies ahead for CPDs within the realm of procedures undertaken in cardiac catheterization laboratories.

Trends and Outcomes of Readmissions Following Post-Procedural Stroke in Patients Undergoing Transcatheter Edge-to-Edge Repair: Insights From the National Readmission Database (2016-2020)

Introduction Transcatheter edge-to-edge repair (TEER) procedure for the repair of significant symptomatic mitral regurgitation has become increasingly popular in recent years. Stroke is a well-known complication of many surgical procedures. However, the association of stroke on outcomes of TEER in patients has not been adequately reported in the literature. Methods We queried the National Readmission Database from 2016 to 2020 using ICD-10 codes to identify the patients admitted for TEER. The patients were divided into two groups: patients with stroke and patients without stroke. Outcomes were assessed between two cohorts at index admissions and readmissions due to stroke. Results A total of 16,719 patients were admitted for TEER procedure, and 97 patients were diagnosed with new onset acute stroke/cerebrovascular accident (CVA). The most common comorbidities in the study population admitted with acute CVA were hypertension, hyperlipidemia, history of nicotine use, and coronary artery disease. On multivariate regression analysis, patients admitted with acute CVA compared to the patients without acute CVA had significantly higher odds of in-hospital mortality, acute kidney injury, post-procedural bleeding, acute myocardial infarction, and mechanical circulatory support. Conclusion Patients in the acute CVA group had higher rates of readmissions, mean length of stay in the hospital, and higher healthcare burden.

Thromboaspiration of a left-sided bioprosthetic valve thrombosis by a mini-access: the Lausanne novel procedure

Left-sided bioprosthesis valve thrombosis (LSBVT) is a challenging complication necessitating invasive interventions. In this study, we introduce a novel, minimally invasive approach. We used a cerebral embolic protection system and an Occlutech cannula connected to an extracorporeal circuit, providing safer thrombus aspiration compared to the AngioVac system. This technique offers a promising alternative for high-risk patients with LSBVT.

Clinical impact of cerebral protection during transcatheter aortic valve implantation

BACKGROUND

Embolization of debris can complicate transcatheter aortic valve implantation (TAVI) causing stroke. Cerebral embolism protection (CEP) devices can divert or trap debris.

PURPOSE

To evaluate the efficacy of CEP during TAVI vs the standard procedure.

DATA SOURCES

PubMed, SCOPUS and DOAJ 1/01/2014-04/12/2023.

STUDY SELECTION

Randomized and observational studies comparing CEP versus standard TAVI, according to PRISMA.

PRIMARY OUTCOME

stroke.

SECONDARY OUTCOMES

death, bleeding, vascular access complications, acute kidney injury and infarct area.

DATA EXTRACTION

Two investigators independently assessed study quality and extracted data.

DATA SYNTHESIS

Twenty-six articles were included (540.247 patients). The primary endpoint was significantly lower (RR = 0.800 95%CI:0.682-0.940; p = 0.007) with CEP. Similarly, death rates were significantly lower with CEP (RR = 0.610 95%CI:0.482-0.771; p < 0.001). No difference was found for bleeding (RR = 1.053 95%CI:0.793-1.398; p = 0.721), vascular complications (RR = 0.937 95%CI:0.820-1.070; p = 0.334) or AKI (RR = 0.982 95%CI:0.754-1.279; p = 0.891).

CONCLUSIONS

Use of CEP during TAVI is associated with improved outcomes. Future studies will identify patients who benefit most from CEP.

Regional differences in the utilization and outcomes of cerebral embolic protection during transcatheter aortic valve replacement: an analysis of the National Inpatient Sample from 2017 through 2019

Aim: To evaluate the utilization and outcomes of cerebral embolic protection (CEP) during transcatheter aortic valve replacement (TAVR) by USA region, using discharge data from the National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Patients & methods: All TAVR discharge encounters from June 2017-2019 were included in the analysis. Discharge encounters with bicuspid anatomy were excluded. Regional CEP utilization rates were reported. For TAVR cases performed with the Sentinel CEP device (Boston Scientific, MA, USA), multivariable logistic regression was performed to model regional differences in TAVR outcomes including: stroke, transient ischemic attack (TIA), stroke/TIA combined, and in-hospital all-cause mortality. Generalized linear regression models were used to assess regional differences in length of stay (LOS) and hospital charges. Results: The Northeast had the greatest overall CEP utilization rate (11.3%), followed by the Midwest (11.1%), West (8.7%), then South (3.1%). Compared with the Northeast, the South was associated with a lower risk of stroke (OR: 0.267, 95% CI: 0.106-0.673; p = 0.005), and the West a higher risk of stroke (OR: 1.583, 95% CI: 1.044-2.401; p = 0.031). Compared with the Northeast, the West was associated with a higher risk of stroke/TIA combined (OR: 1.618, 95% CI: 1.107-2.364; p = 0.013). Compared with the Northeast, the Midwest (OR: 4.501, 95% CI: 2.229-9.089; p < 0.001) and West (OR: 5.316, 95% CI: 2.611-10.824; p < 0.001) were associated with a higher risk of in-hospital all-cause mortality. Adjusted charges and LOS were highest in the West. Conclusion: Within the USA, there are regional differences in the utilization and outcomes of CEP use during TAVR. To prevent regional disparities and ensure consistent quality of care in the USA, further research is needed to determine what variable(s) may be responsible for regional differences in TAVR outcomes, with or without CEP.

Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.

Management of aortic stenosis: a systematic review of clinical practice guidelines and recommendations

Multiple guidelines exist for the management of aortic stenosis (AS). We systematically reviewed current guidelines and recommendations, developed by national or international medical organizations, on management of AS to aid clinical decision-making. Publications in MEDLINE and EMBASE between 1 June 2010 and 15 January 2021 were identified. Additionally, the International Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations were searched. Two reviewers independently screened titles and abstracts. Two reviewers assessed rigour of guideline development and extracted the recommendations. Of the seven guidelines and recommendations retrieved, five showed considerable rigour of development. Those rigourously developed, agreed on the definition of severe AS and diverse haemodynamic phenotypes, indications and contraindications for intervention in symptomatic severe AS, surveillance intervals in asymptomatic severe AS, and the importance of multidisciplinary teams (MDTs) and shared decision-making. Discrepancies exist in age and surgical risk cut-offs for recommending surgical aortic valve replacement (SAVR) vs. transcatheter aortic valve implantation (TAVI), the use of biomarkers and complementary multimodality imaging for decision-making in asymptomatic patients and surveillance intervals for non-severe AS. Contemporary guidelines for AS management agree on the importance of MDT involvement and shared decision-making for individualized treatment and unanimously indicate valve replacement in severe, symptomatic AS. Discrepancies exist in thresholds for age and procedural risk used in choosing between SAVR and TAVI, role of biomarkers and complementary imaging modalities to define AS severity and risk of progression in asymptomatic patients.

Advancements in Transcatheter Aortic Valve Implantation: A Focused Update

Transcatheter aortic valve implantation (TAVI) has become the leading technique for aortic valve replacement in symptomatic patients with severe aortic stenosis with conventional surgical aortic valve replacement (SAVR) now limited to patients younger than 65-75 years due to a combination of unsuitable anatomies (calcified raphae in bicuspid valves, coexistent aneurysm of the ascending aorta) and concerns on the absence of long-term data on TAVI durability. This incredible rise is linked to technological evolutions combined with increased operator experience, which led to procedural refinements and, accordingly, to better outcomes. The article describes the main and newest technical improvements, allowing an extension of the indications (valve-in-valve procedures, intravascular lithotripsy for severely calcified iliac vessels), and a reduction of complications (stroke, pacemaker implantation, aortic regurgitation).