Prevention and Management of Stroke After Transcatheter Aortic Valve Replacement: The Mount Sinai Stroke Initiative
Sahil Khera, A. Koshy, Gilbert H.L. Tang, Pedro Moreno, Roxana Mehran, George Dangas, David Bronster, Annapoorna Kini, Michael Fara, Samin K. Sharma
Abstract
troke is a devastating complication following transcatheter aortic valve replacement (TAVR).Despite advancements in technology, procedural technique, operator experience, and use of cerebral embolic protection, stroke rates have remained unchanged. 1,2There is a paucity of data on the optimal management of patients with stroke following TAVR.Timely decision-making regarding the suitability for thrombolysis or mechanical thrombectomy in post-TAVR patients with documented stroke can be challenging because of the inherent mechanism of stroke, high-risk vascular anatomy, and patient comorbidities. 3,4A multidisciplinary stroke initiative was established to develop an institutional algorithm for the risk mitigation and management of suspected stroke following TAVR.We present the results of our working group recommendations as well as preliminary findings 1 year after protocol implementation.The Mount Sinai Stroke Initiative included members from interventional cardiology, neurology, and cardiothoracic surgery.The aims of the working group were 2-fold.First, based on expert consensus, we aimed to formalize institutional strategies to mitigate stroke risk in patients undergoing TAVR.Second, we proposed a streamlined protocol for the management of patients diagnosed with stroke after TAVR.After review of existing literature, the stroke prevention recommendations were avoidance of postprocedural balloon valvuloplasty when possible, pharmacotherapy (day before admission and heparin infusion in patients with CHA2DS2VASC 5 and minimizing anticoagulation interruption in patients undergoing TAVR), and selective cerebral embolic protection (any 1 of: severely calcified valves, bicuspid valves, valve-in-valve, prior stroke, patients with atrial fibrillation, and CHA2DS2VASC score5).A key objective of the stroke management protocol was to minimize decision points to reduce individual practitioner preferences.The management decision flowchart is shown in Figure A.Overall, 2133 transfemoral TAVR procedures from January 1, 2017 to July 10, 2022, were included.Stroke after TAVR was confirmed by the consulting neurologist based on clinical presentation and neuroimaging findings.The stroke protocol implementation date was March 4, 2021, and the patients were divided into 2 groups-preimplementation (N=1421) and postimplementation (N=712).Baseline characteristics were compared using 2 test or Fisher exact test for categorical variables and paired t or Mann-Whitney U test for continuous variables.