How to Prevent Thromboembolic Complications in TAVI
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1 How to Prevent Thromboembolic Complications in TAVI PETER WENAWESER, MD Swiss Cardiovascular Centre, University Hospital, Bern, Switzerland
2 Potential Conflicts of Interest Proctoring and lecture fees from Medtronic, Edwards Lifesciences and Boston Scientific
3 Objectives/Learning Issues To understand neurological complications To learn the actual rate of these complications in contemporary series To develop clinical strategies to decrease these complications
4 Prevalence of Stroke in the US Roger VL et al. Circulation 2011; 123: e18-e209 % Men 14,5 14,8 Women 8,2 7,2 1,6 2,4 0,3 0, Age
5 Female Gender Systemic Hypertension Stroke Risk Active Smoking Diabetes Mellitus Profile D Agostino RB et al. Stroke 1994;25:40-3 Atrial Fibrillation LV Hypertrophy
6 Aortic Stenosis Patients S. E., 83 YO Female 10-Year Stroke Probability Medical History: Chronic Obstructive Pulmonary Disease 100 Chronic Renal Failure (Clearance 35ml/min) Permanent % Atrial Fibrillation Cardiac Risk Factors: 70 Systemic Hypertension 60 History of Present Illness 50 Cardiac decompensation TTE/TEE: severe AS (AVA 0.7cm 2 ), LV Hypertrophy 40 Systemic Hyperten sion Diabetes Mellitus Female Gender Stroke Risk Profile LV Hypertrophy Active Smoking Atrial Fibrillation Heart 30 Catheterization 23,9 20 Coronary artery disease (75% LAD) Logistic 10 EuroScore 21.2%; STS Score 12.9% 0 Calculated Risk Expected Risk D Agostino RB et al. Stroke 1994;25:40-3
7 Assessment of Aortic Arch Atheroma by TEE and Correlation With Aortic Stenosis Osranek et al, Am J Cardiol 2009;103: Prevalence of severe aortic atheroma increased with severity of aortic stenosis 54% of patients with severe aortic stenosis had severe aortic arch atheroma 61% of patients >65years with severe aortic stenosis had severe aortic arch atheroma
8 Fuchs et al., Circulation 2002; 106 Isolated Valve % PCI 0.4% CABG and Valve 7.4% Stroke due to CV Interventions Isolated CABG % Double Valve 9.7% TAVI 0 9.6% Selim et al. NEJM 2007;356:706-13
9 Incidence of Major/Disabling Stroke in TAVI/SAVR
10 Cerebrovascular Events After 30 Days and 1 Year Partner A Cohort Smith et al. NEJM 2011;364: % Major Stroke p = 0.20 p = 0.07 All Stroke or TIA p = ,3 p = ,8 5,1 5,5 4,3 3 2,1 2,4 2, Days 1 Year 30 Days 1 Year TAVI (n=348) SAVR (n=351)
11 All-Cause Mortality or Stroke All Patients (n=699) TAVR AVR 28.0 HR [95% CI] = 0.95 [0.73, 1.23] P (log rank) = No. at Risk Months TAVI SAVR
12 All Stroke ACC
13 Impact of Stroke on Mortality
14
15 STS=7 J.Webb Euro-PCR 2014
16 Incidence of Major/Disabling Stroke in TAVI Patients In high-risk patients: 3-5 % In intermediate risk patients: 1-3%
17 Incidence of Silent Brain Ischemia?
18 Cerebral Ischemia After TAVI Kahlert PK et al. Circulation 2010;121: New Lesions Lesion Volume % mm
19 Transcranial Doppler Sound Detection of Cerebrovascular Microembolism Erdös G et al. EJCTS 2011 Transfemoral vs. Transapical TAVI Self- vs. Ballonexpandable TAVI
20 Mechanism of Thromboembolic Events Stortecky et al 2014
21 Therapeutic Options for Stroke Prevention Drugs Risk assessment Protection Devices
22 Summary Stroke remains an important issue for patients undergoing TAVI Further improvements in the field of antiplatelet and anticoagulation treatment are warranted The role of protection devices need be determined
23 Thank you PETER WENAWESER, MD Swiss Cardiovascular Centre, University Hospital, Bern, Switzerland
24 AK St Georg Study Embolic debris captured during TAVI procedures at AK St Georg (Hamburg RECAPTURE) 52 cases of TAVI using Claret Medical Cerebral Protection System performed at AK St Georg (Hamburg) Using Sapien S3/XT, CoreValve, etc. valves Filter contents subsequently analyzed by CVPath Institute Debris captured in 96% of patients ACUTE THROMBUS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cerebral embolic debris captured in TAVI patients (n=52) Any debris Acute thrombus Organizing thrombus Valve Tissue Arterial Wall Calcification Note: percentages reflect percent of filters in the series in which each particular tissue type was captured. Some filters captured several types of debris, so percentages will not add to 100% 1. Schmidt T, Schaefer U, Sanchez O, et al DGK CVPath Institute data on file at Claret Medical. Foreign material ORGANIZED THROMBUS ARTERIAL WALL VALVE TISSUE THROMBUS WITH CALCIFIED DEBRIS
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