Embolic Cerebral Insults After
Percutaneous Aortic Valve
Replacement
Detected by Magnetic Resonance
Imaging
Stephan M. Ensminger, Martin Arnold, Susanne Schulz-Heise, Arnd Doerfler,
Friedrich Einhaus, Stephan Achenbach, Richard Feyrer, Dieter Ropers,
Werner G. Daniel, Michael Weyand, Josef Ludwig
Departments of Cardiac Surgery, Cardiology and Radiology
University Hospital Erlangen
Germany
I will not discuss off label use and/or investigational use.
The following relevant financial relationships exist related
to my or any other author´s role in this session:
No relationships to disclose
Stroke Risk: Passage of calcified aortic valve
3
Stroke Risk: Valvuloplasty
4
Stroke Risk: Positioning and implantation of prosthesis
5
Stroke Risk: Hypotension during “rapid pacing“
6
Clinical rate of stroke following TAVI
7
Bauernschmitt et .al
2009
n=149
7%
Al-Attar et al.
2009
n=50
4/50 (8%)
Thielmann et al.
2009
n=39
1/39 (3%)
Ye et al.
2009
n= 26
1/26 (4%)
Walther, et al.
2008
n= 50
0%
Grube, et al.
2007
n= 86
10%
Imaging of cerebral lesions by MRI before and within 7
days after transapical TAVI in 25 patients
Diffusion Weigthed Imaging (DWI)
(Most sensitive method for early visualization of ischemia driven diffusion
abnormalities)
FLAIR sequences
(to quantify lesion size)
T2 weightes sequenzes
(to quantify lesion size)
T2 weighted gradient echo FLASH sequences
(to differentiate bleeding and ischemia)
8
25 patients
9
Gender (f/m)
15 / 10
Age (years)
81 ± 5
Log. EUROSCORE (%)
32,3 ± 10
LV-EF (%)
51 ± 14
AVA (cm2)
0,8 ± 0,2
Atrial fibrillation (pre-operative) (n)
15
Earlier stroke (n)
6
Carotid stenosis > 50% (n)
9
Creatinine (mg/dl)
1,25 ± 0,6
pro NT-pro BNP (U/l)
6354 ± 9571
NYHA
III (I; IV)
Procedure duration (min)
111 ± 30
Fluoroscopy time (min)
10 ± 5
Postoperative ventilation > 24 hours (n)
2
Valve Size
23 mm (n)
26 mm (n)
7
18
Evidence of Post Procedure Ischemic Lesions
68%
9
8
Number of new lesions:
7
6
5
4
3
2
8
4
1
7
6
0
1
2
3
1:
2:
3:
4:
No new lesion
1 new lesion
2 -5 new lesions
> 5 new lesions
4
12
Size of lesions:
10
8
6
4
4
11
2
2
0
1
2
1: < 5 mm
2: < 10 mm
3: > 10 mm
3
All lesions of typical morphology for embolism
10
Example 1
Symptomatic
stroke.
> 5 lesions up to
41 mm
11
Example 2
> 5 lesions up
to 12 mm.
Clinically
asymptomatic.
12
Affected Vascular Territories
4
27%
1
38%
3
2%
2
33%
1 = Arteria cerebri media, 2 = Arteria cerebri posterior
artery, 3 = Arteria cerebri anterior, 4 = Cerebellum/
Hirnstamm.
13
Clinical Events:
Patient
Clinical
MRI
79 J,
w, 26 mm Sapien,
120min OP, Fl 9.8 min, Afib,
pVD.
Severe stroke,
reduced vigilance
> 5 lesions, max. 41
mm
78 J,
m, 26 mm Sapien, 65
min OP, Fl 5.5 min., Afib, pVD
TIA (vision)
Singular brain stem
lesion
72 J,
m, 26 mm Sapien, 170
min OP, stroke, PHT.
Transitory psychotic
syndrome
> 5 Lesions,
76 J,
m, 26 mm Sapien, 95
min OP, Fl 15.7 min, EF 20%,
CAD, pVD, A fib, right carotid
occlusion.
Transitory psychotic
syndrome
> 5 Lesions,
84 J,
Transitory psychotic
syndrome
No lesion
w, 23 mm Sapien, 65
min OP, Fl 5.7 min, EF 35%,
carotic stenosis (~50%)
bilaterally.
14
3rd postoperative
day
> 7mm.
> 7mm.
Results Summary
 New embolic cerebral lesions seen in more than 2/3 of patients
(68%) after transapical TAVI
 Clinical symptoms are infrequent (15%)
 Size and number of lesions not tied to symptoms.
15
Other Publications:
Transfemoral
N = 31
0% (0) stroke
87% (16) lesions
Circulation 2010
Transfemoral
N = 22
4% (1) stroke
73% (16) lesions
JACC 2010
16
Conclusion
 New embolic ischemic cerebral insults are detected in 68%
of patients after transapical valve replacement.
 Clinical symptoms are rare and usually transitory.
 Larger trials will need to establish the clinical significance of
asymptomatic ischemic lesions as well as the rate of
ischemic events in transfemoral/transapical/surgical aortic
valve replacement.
17