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Agrawal A, Isogai T, Shekhar S, Kapadia S. Cerebral Embolic Protection Devices: Current State of the Art. US Cardiology Review 2023. [DOI: 10.15420/usc.2022.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become a first-line treatment for severe aortic stenosis with intermediate to high-risk population with its use increasingly expanding into younger and low-risk cohorts as well. Cerebrovascular events are one of the most serious consequential complications of TAVR, which increase morbidity and mortality. The most probable origin of such neurological events is embolic in nature and the majority occur in the acute phase after TAVR when embolic events are most frequent. Cerebral embolic protection devices have been designed to capture or deflect these emboli, reducing the risk of peri-procedural ischaemic events. They also carry the potential to diminish the burden of new silent ischemic lesions during TAVR. Our review explores different types of these device systems, their rationale, and the established clinical data.
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Affiliation(s)
- Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, Spilias N, Shekhar S, Saad AM, Verma BR, Puri R, Reed GW, Popović ZB, Unai S, Yun JJ, Uchino K, Kapadia SR. Cerebral embolic protection and severity of stroke following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2022; 100:810-820. [PMID: 35916117 PMCID: PMC9805232 DOI: 10.1002/ccd.30340] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The cerebral embolic protection (CEP) device captures embolic debris during transcatheter aortic valve replacement (TAVR). However, the impact of CEP on stroke severity following TAVR remains unclear. Therefore, we aimed to examine whether CEP was associated with reduced severity of stroke following TAVR. METHODS This was a retrospective cohort study of 2839 consecutive patients (mean age: 79.2 ± 9.5 years, females: 41.5%) who underwent transfemoral TAVR at our institution between 2013 and 2020. We categorized patients into Sentinel CEP users and nonusers. Neuroimaging data were reviewed and the final diagnosis of a cerebrovascular event was adjudicated by a neurologist blinded to the CEP use or nonuse. We compared the incidence and severity (assessed by the National Institutes of Health Stroke Scale [NIHSS]) of stroke through 72 h post-TAVR or discharge between the two groups using stabilized inverse probability of treatment weighting (IPTW) of propensity scores. RESULTS Of the eligible patients, 1802 (63.5%) received CEP during TAVR and 1037 (36.5%) did not. After adjustment for patient characteristics by stabilized IPTW, the rate of overall stroke was numerically lower in CEP users than in CEP nonusers, but the difference did not reach statistical significance (0.49% vs. 1.18%, p = 0.064). However, CEP users had significantly lower rates of moderate-or-severe stroke (NIHSS ≥ 6: 0.11% vs. 0.69%, p = 0.013) and severe stroke (NIHSS ≥ 15: 0% vs. 0.29%, p = 0.046). Stroke following CEP use (n = 8), compared with stroke following CEP nonuse (n = 15), tended to carry a lower NIHSS (median [IQR], 4.0 [2.0-7.0] vs. 7.0 [4.5-19.0], p = 0.087). Four (26.7%) out of 15 patients with stroke following CEP nonuse died within 30 days, with no death after stroke following CEP use. CONCLUSIONS CEP use may be associated with attenuated severity of stroke despite no significant difference in overall stroke incidence compared with CEP nonuse. This finding is considered hypothesis-generating and needs to be confirmed in large prospective studies.
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Affiliation(s)
- Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | | | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Anas M. Saad
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Beni Rai Verma
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Grant W. Reed
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Zoran B. Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - James J. Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Ken Uchino
- Cerebrovascular Center, Neurological InstituteCleveland ClinicClevelandOHUSA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
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Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, Spilias N, Shekhar S, Saad AM, Verma BR, Puri R, Reed GW, Popović ZB, Unai S, Yun JJ, Uchino K, Kapadia SR. Feasibility of Sentinel Cerebral Embolic Protection Device Deployment During Transfemoral Transcatheter Aortic Valve Replacement. Am J Cardiol 2022; 184:157-159. [PMID: 36192198 DOI: 10.1016/j.amjcard.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | | | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Anas M Saad
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Beni Rai Verma
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James J Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute.
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Jagielak D, Targonski R, Frerker C, Abdel-Wahab M, Wilde J, Werner N, Lauterbach M, Leick J, Grygier M, Misterski M, Erglis A, Narbute I, Witkowski AR, Adam M, Frank D, Gatto F, Schmidt T, Lansky AJ. Safety and performance of a novel cerebral embolic protection device for transcatheter aortic valve implantation: the PROTEMBO C Trial. EUROINTERVENTION 2022; 18:590-597. [PMID: 35608032 PMCID: PMC10241272 DOI: 10.4244/eij-d-22-00238] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/28/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stroke remains a feared complication associated with transcatheter aortic valve implantation (TAVI). Embolic cerebral injury occurs in the majority of TAVI cases and can lead to cognitive dysfunction. AIMS The PROTEMBO C Trial evaluated the safety and performance of the ProtEmbo Cerebral Protection System in TAVI patients. METHODS Forty-one patients were enrolled in this single-arm study conducted at 8 European centres. The primary safety endpoint was the rate of VARC 2-defined major adverse cardiac and cerebrovascular events (MACCE) at 30 days; the primary performance endpoint was the composite rate of technical success versus performance goals (PG). Secondary endpoints included brain diffusion-weighted magnetic resonance imaging (DW-MRI), new lesion volume, and the rate of death or all strokes compared to historical data. RESULTS Thirty-seven of 41 enrolled patients underwent TAVI with the ProtEmbo device (intention-to-treat [ITT] population). Both primary endpoints were met. MACCE at 30 days was 8.1% (upper limit of the 95% confidence interval [CI]: 21.3% vs PG 25%; p=0.009), and technical success was 94.6% (lower limit of the 95% CI: 82.3% vs PG 75%; p=0.003). New DW-MRI lesion volumes with ProtEmbo were smaller than in historical data, and 87% of patients completing MRI follow-up had no single lesion >150 mm3. There was 1 stroke in a patient in whom the device was removed prematurely before TAVI completion. CONCLUSIONS The PROTEMBO C Trial met its primary safety and performance endpoints compared to prespecified historical PGs. Patients had smaller brain lesion volumes on DW-MRI compared to prior series and no larger single lesions. These results warrant further evaluation of the ProtEmbo in a larger randomised controlled trial (RCT).
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Affiliation(s)
- Dariusz Jagielak
- Department of Cardiac & Vascular Surgery, Uniwersyteckie Centrum Kliniczne, Gdansk, Poland
| | - Radoslaw Targonski
- Department of Cardiac & Vascular Surgery, Uniwersyteckie Centrum Kliniczne, Gdansk, Poland
| | | | | | - Johannes Wilde
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Nikos Werner
- Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | | | - Juergen Leick
- Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Misterski
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrejs Erglis
- Pauls Stradiņš Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Inga Narbute
- Pauls Stradiņš Clinical University Hospital, University of Latvia, Riga, Latvia
| | | | - Matti Adam
- University Hospital Cologne, Cologne, Germany
| | - Derk Frank
- UKSH University Medical Center Schleswig-Holstein, Kiel, Germany
- DZHK Partner Site Hamburg/Kiel/Lübeck, Germany
| | | | | | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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Isogai T, Bansal A, Vanguru HR, Agrawal A, Shekhar S, Puri R, Reed GW, Krishnaswamy A, Uchino K, Kapadia SR. Cerebral Embolic Protection and Stroke-Related Mortality Following Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2022; 15:569-571. [PMID: 35272784 DOI: 10.1016/j.jcin.2022.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/20/2021] [Accepted: 01/04/2022] [Indexed: 11/15/2022]
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