What is the risk of stroke post-Transcatheter Aortic Valve Replacement (TAVR) and how is it managed?

Stroke Risk and Management After Transcatheter Aortic Valve Replacement (TAVR)

Stroke is a significant complication after TAVR, occurring in 3.9% of patients, with approximately half being disabling strokes that significantly increase 30-day mortality. 1

Incidence and Risk Factors

The risk of stroke after TAVR varies depending on several factors:

• Overall incidence: 1.5-6% of patients experience stroke post-TAVR 2
• Timing of stroke occurs in three distinct phases:
  1. Early high-risk phase (procedure-related)
  2. Elevated risk between days 2-30
  3. Late hazard interval 3

Key Risk Factors

• Prior history of stroke (OR = 1.83) 1
• Operator experience (higher risk with less experienced teams) 1
• Advanced age and higher surgical risk profile 2

Stroke Types and Characteristics

• Predominant type: Territorial ischemic lesions (82.4%) 1
• Location distribution:
  • Left-sided lesions: 45.6%
  • Right-sided lesions: 25%
  • Bilateral lesions: 13.2% 1
• Primary bleeding accounts for only 4.4% of strokes 1

Management Approach

Immediate Post-TAVR Monitoring

• Continuous electrocardiogram monitoring for at least 3 days 4
• Early mobilization and extubation when possible 4
• Careful monitoring of vital parameters and access sites 4

Acute Stroke Management

For major ischemic stroke:

• Urgent consultation with stroke neurologist or neurosurgeon 4
• Consider catheter-based mechanical embolic retrieval for large disabling strokes 4
• Angiography and stroke intervention may be recommended at comprehensive stroke centers 4

For minor ischemic stroke:

• Aspirin therapy 4
• Evaluate for other potential causes of stroke (carotid/vertebral stenosis, cardiac sources) 4

For hemorrhagic stroke:

• Reversal of anticoagulation
• Correction of coagulopathy with fresh-frozen plasma or other transfusions 4

Prevention Strategies

Recent evidence strongly supports the use of cerebral protection devices:

• The Sentinel™ Cerebral Protection System reduces cerebrovascular events by 76% (OR 0.24,95% CI 0.08-0.76) 5
• Benefits include:
  • Shorter length of hospital stay
  • Lower 12-month all-cause mortality (OR 0.45; 95% CI 0.22-0.93) 5

Antithrombotic Therapy

Post-TAVR antithrombotic recommendations from ACC guidelines:

• Aspirin 75-100 mg daily for 3-6 months 4
• Consider warfarin (INR 2.0-2.5) for patients at risk of atrial fibrillation or venous thromboembolism 4
• If atrial fibrillation is present, institute oral anticoagulant therapy 4

Long-term Follow-up

• Echocardiography at 30 days and then annually 4
• ECG at 30 days and annually 4
• Consider 24-hour ECG monitoring if bradycardia is present 4
• Ongoing monitoring for cardiac conduction defects (may be delayed up to 30 days) 4
• Regular assessment of prosthetic valve function 4

Clinical Impact and Prognosis

Stroke after TAVR significantly impacts outcomes:

• 30-day mortality: 13.2% in patients with stroke vs. 4.9% in those without stroke 1
• Increased morbidity and reduced functional status 2

Pitfalls and Caveats

1. Don't miss delayed heart block: Although heart block occurs usually early after TAVR, it may be delayed up to 30 days, requiring enhanced surveillance 4

2. Be aware of device-specific risks: Self-expanding valves (CoreValve) have higher rates of heart block and pacemaker implantation than balloon-expandable valves 4

3. Consider anatomical factors: Bulky calcification, small sinotubular junction, and smaller annular size increase risk of complications 4

4. Recognize paravalvular regurgitation: This is associated with adverse outcomes and requires careful monitoring 4

5. Don't overlook the importance of operator experience: Initial TAVR experience (first 300 cases) is associated with nearly double the risk of stroke (OR = 1.95) 1