Cerebrovascular Events in Patients Undergoing Transcatheter Aortic Valve Replacement: A Review.

IF 7.8 1区 医学 Q1 CLINICAL NEUROLOGY Stroke Pub Date : 2024-11-01 Epub Date: 2024-10-07 DOI:10.1161/STROKEAHA.124.047149
Kush P Patel, Krishnaraj S Rathod, Alexandra J Lansky, Bernard Prendergast, Rajesh K Kharbanda, Anthony Mathur, Richard Perry, Andreas Baumbach
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Abstract

Cerebrovascular events (CVEs) are a dreaded complication of transcatheter aortic valve replacement (TAVR). They are associated with significant mortality, morbidity, and reduced quality of life and impose a significant burden to health care systems. Although the rates of clinical stroke have reduced since the advent of TAVR, it remains an important complication, particularly as TAVR is increasingly utilized. CVE may occur at the time of the TAVR, as a direct consequence of the procedure, or may occur later, related to thrombosis of the prosthetic valve, atrial fibrillation, and other comorbidities. Imaging of the brain has revealed a high prevalence of subclinical cerebral infarcts (68%-98%) associated with the TAVR procedure. Although their clinical significance has not been fully established, clinically evident CVE ranges between 3% and 5% in patients considered at high operative risk to between 1% and 3% in low operative risk patients. Periprocedural CVEs are largely the result of embolization of the thrombus and tissue derived from the valve, vasculature, or myocardium. Cerebral embolic protection devices have been studied in multiple trials, with some evidence supporting a reduction in new cerebral lesion volume, number, and potentially disabling strokes. However, thus far, there is no robust evidence that they reduce the overall stroke rate. The number and severity of comorbidities, in particular, new-onset atrial fibrillation, are associated with CVEs. Valve thrombosis diagnosed using computed tomography as areas of hypoattenuated leaflet thickening has been identified in 10% to 15% of patients. This is a dynamic process associated with an increase in CVEs, but that resolves with anticoagulation or sometimes without it. Routine use of anticoagulation compared with a single antiplatelet agent is associated with an increased risk of bleeding, without any additional alleviation in risk of thromboembolism. Future studies to improve risk stratification could facilitate the tailoring of preventive therapies to patients at high risk of CVE, who stand to gain the most benefit.

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经导管主动脉瓣置换术患者的脑血管事件:综述。
脑血管事件(CVEs)是经导管主动脉瓣置换术(TAVR)的一种可怕并发症。它们与严重的死亡率、发病率和生活质量下降有关,给医疗保健系统带来了沉重的负担。虽然自 TAVR 问世以来临床卒中的发生率有所下降,但它仍然是一个重要的并发症,尤其是随着 TAVR 的应用越来越广泛。CVE 可能发生在 TAVR 术中,是手术的直接后果,也可能发生在术后,与人工瓣膜血栓形成、心房颤动和其他合并症有关。脑部成像显示,与 TAVR 手术相关的亚临床脑梗塞发生率很高(68%-98%)。虽然其临床意义尚未完全确定,但临床上明显的 CVE 在高手术风险患者中占 3% 至 5%,在低手术风险患者中占 1% 至 3%。围手术期 CVE 主要是瓣膜、血管或心肌中的血栓和组织栓塞的结果。多项试验已对脑栓塞保护装置进行了研究,一些证据支持该装置可减少新发脑损伤的体积、数量和潜在的致残性中风。然而,到目前为止,还没有强有力的证据表明它们能降低总体中风率。合并症的数量和严重程度,尤其是新发心房颤动,与 CVEs 相关。10%至15%的患者通过计算机断层扫描诊断出瓣膜血栓形成,表现为瓣叶增厚过低。这是一个动态过程,与 CVE 的增加有关,但在抗凝治疗后或有时无需抗凝治疗即可缓解。与单一抗血小板药物相比,常规使用抗凝药物会增加出血风险,但不会额外降低血栓栓塞的风险。未来为改善风险分层而进行的研究将有助于为CVE高风险患者量身定制预防性疗法,这些患者将从中获益最多。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Stroke
Stroke 医学-临床神经学
CiteScore
13.40
自引率
6.00%
发文量
2021
审稿时长
3 months
期刊介绍: Stroke is a monthly publication that collates reports of clinical and basic investigation of any aspect of the cerebral circulation and its diseases. The publication covers a wide range of disciplines including anesthesiology, critical care medicine, epidemiology, internal medicine, neurology, neuro-ophthalmology, neuropathology, neuropsychology, neurosurgery, nuclear medicine, nursing, radiology, rehabilitation, speech pathology, vascular physiology, and vascular surgery. The audience of Stroke includes neurologists, basic scientists, cardiologists, vascular surgeons, internists, interventionalists, neurosurgeons, nurses, and physiatrists. Stroke is indexed in Biological Abstracts, BIOSIS, CAB Abstracts, Chemical Abstracts, CINAHL, Current Contents, Embase, MEDLINE, and Science Citation Index Expanded.
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