What is the management of stroke post Transcatheter Aortic Valve Implantation (TAVI)?

Management of Stroke Post Transcatheter Aortic Valve Implantation (TAVI)

Stroke after TAVI requires immediate neurological assessment and management with a focus on rapid revascularization when appropriate, followed by optimized antithrombotic therapy based on patient-specific factors.

Epidemiology and Risk Factors

Stroke is a serious complication of TAVI with significant impact on morbidity and mortality:

• Incidence of cerebrovascular events post-TAVI is approximately 3.2% in real-world populations 1
• 60% of these events are classified as strokes with symptoms persisting >24 hours 1
• 50% of strokes are major strokes leading to notable disability 1
• Stroke increases in-hospital mortality from 6.9% to 28.9% and 1-year mortality from 18.6% to 46.7% 1

Independent risk factors for stroke after TAVI include:

• Prior stroke history 1
• Renal impairment 1
• New-onset atrial fibrillation post-TAVI (4.4-fold increased risk) 2
• Baseline aortic regurgitation grade III or greater (3.2-fold increased risk) 2

Timing of Stroke

Timing of stroke post-TAVI is important for understanding mechanisms and prevention:

• Early stroke (≤24 hours): 42% of cases 2
• Delayed stroke (>24 hours): 58% of cases 2

This timing distribution highlights the importance of both procedural factors and post-procedural care in stroke prevention.

Acute Management of Stroke Post-TAVI

1. Immediate Neurological Assessment

   • Rapid neurological evaluation using standardized stroke scales
   • Urgent brain imaging (CT or MRI)

2. Revascularization Therapy

   • For ischemic stroke within appropriate time windows:
     • IV thrombolysis if within 4.5 hours of symptom onset and no contraindications
     • Mechanical thrombectomy for large vessel occlusion if within 24 hours

3. Supportive Care

   • Blood pressure management
   • Maintenance of normoglycemia
   • Prevention of complications (aspiration, deep vein thrombosis)

Antithrombotic Management Post-Stroke

The antithrombotic regimen should be adjusted based on stroke type and patient factors:

1. For patients without indication for oral anticoagulation:

   • Single antiplatelet therapy (typically aspirin) is recommended 3
   • Avoid dual antiplatelet therapy unless there is recent coronary stenting 3

2. For patients with indication for oral anticoagulation (e.g., atrial fibrillation):

   • Oral anticoagulation monotherapy is recommended 3
   • Avoid combination therapy with antiplatelet agents to reduce bleeding risk 3

3. Special considerations:

   • After recent coronary stenting: Consider a limited period of dual therapy (P2Y12 inhibitor plus OAC) 3
   • For hemorrhagic stroke: Temporarily withhold antithrombotics and reassess risk/benefit for resumption

Prevention of Recurrent Stroke

1. Atrial Fibrillation Management

   • Given the strong association between new-onset AF and stroke post-TAVI 2, vigilant monitoring and prompt management of AF is essential
   • Consider anticoagulation for patients who develop AF post-TAVI

2. Blood Pressure Control

   • Target blood pressure <130/80 mmHg after acute phase

3. Lipid Management

   • High-intensity statin therapy

4. Cerebral Protection Devices

   • Current evidence does not support routine use of cerebral embolic protection devices during TAVI 4, 5
   • The PROTECTED TAVI trial (NCT04149535) may provide further guidance 5

Long-term Follow-up

1. Regular clinical assessment

   • Neurological status evaluation
   • Functional status assessment

2. Echocardiographic surveillance

   • Every 6 months for valve function assessment 6
   • Monitor for subclinical valve thrombosis which may be associated with cerebral embolism 4

3. Optimization of cardiovascular risk factors

   • Diabetes management
   • Smoking cessation
   • Weight management

Key Pitfalls to Avoid

1. Delayed recognition of stroke symptoms

   • Implement standardized post-TAVI neurological checks
   • Educate healthcare staff on recognition of subtle stroke symptoms in elderly patients

2. Inadequate monitoring for atrial fibrillation

   • Given its strong association with post-TAVI stroke 2, continuous cardiac monitoring should be implemented in the early post-procedural period

3. Excessive antithrombotic therapy

   • Combination antithrombotic therapy increases bleeding risk without clear benefit in stroke prevention 3
   • Tailor therapy based on individual patient risk factors

4. Overlooking delayed stroke risk

   • Since 58% of strokes occur >24 hours post-procedure 2, vigilance must extend beyond the immediate post-procedural period

By implementing this comprehensive approach to stroke management post-TAVI, clinicians can optimize outcomes for this serious complication that significantly impacts patient morbidity and mortality.