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Ghanem et al., J Am Coll Cardiol 2010;55:1427–32.

Ghanem et al., J Am Coll Cardiol 2010;55:1427–32. Background  . Aortic valve replacement is recommended in patients with symptomatic severe valvular stenosis. Transfemoral aortic valve implantation (TAVI) offers a therapeutic option for high-risk patients with multiple comorbid conditions.

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Ghanem et al., J Am Coll Cardiol 2010;55:1427–32.

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  1. Ghanem et al., J Am Coll Cardiol 2010;55:1427–32.

  2. Background  • Aortic valve replacement is recommended in patients with symptomatic severe valvular stenosis. • Transfemoral aortic valve implantation (TAVI) offers a therapeutic option for high-risk patients with multiple comorbid conditions. Vahanian et al., European Journal of Cardiothoracic Surgery 34 (2008)

  3. Background • TAVI-related stroke is an important complication (1-10%). The risk of silent cerebral embolism is not elucidated yet. • Diffusion-weighted MRI allows detection and localization of acute - apparent and silent - ischemic cerebral lesions. • DW-MRI studies are of potential interest for pre-interventional risk stratification, peri-interventional anticoagulation management... Grube et al., JACC (2007), Webb et al., Circulation (2008), Zajarias et al., JACC (2009)

  4. Background Aim of the study: Prospective investigation of peri-interventional cerebral embolism (3rd generation Corevalve™-Prosthesis) with DW-MRI and its relationship with clinical (NIHSS) and serological (NSE) parameters of brain injury. • TAVI-related stroke is an important complication (1-10%). The risk of silent cerebral embolism is not elucidated yet. • Diffusion-weighted MRI allows detection and localization of acute - apparent and silent - ischemic cerebral lesions. • DW-MRI studies are of potential interest for pre-interventional risk stratification, peri-interventional anticoagulation management... Grube et al., JACC (2007), Webb et al., Circulation (2008), Zajarias et al., JACC (2009)

  5. Study design Inclusion criteria: • severe,symptomatic aortic stenosis with or without regurgitation and high peri-operative riskor • explicit patient‘s request and • aortic valve annulus diameter >20 and <27 mm, and • diameter of the ascending aorta <45 mm at the sinotub. junction. Exclusion criteria: • Age < 18 years • Pregnancy / lactation period • Contraindications to MRI (PM, ICD, Claustrophobia …)

  6. Study design Evaluation Clinical and neurological assessment (NIHSS) Lab - Tests (incl. Lactate, NSE) MRI TAVI Clinical and neurological assessment (NIHSS) Lab - Tests (incl. Lactate, NSE) MRI Clinical and neurological assessment (NIHSS) Lab - Tests (incl. Lactate, NSE) MRI E1 E2 E3

  7. Protocol • E1 • DW-MRI • NIHSS (n=30) • NSE • Death (n=2) • New onset of claustrophobia (n=1) • Hemodynamic instability (n=1) • PM-Therapy (n=4) TAVI E2 • DW-MRI (n=22) • NIHSS • NSE E3 • DW-MRI (n=22) • NIHSS • NSE

  8. Baseline characteristics

  9. Serology E1 E2 E3 E1 E2 E3

  10. MRI

  11. Lesion localisation and size

  12. NIHSS E1 E2 E3

  13. Results • DW-MRI, but not NSE, detects cerebral embolic lesions. • Silent cerebral embolism is freuquent following TAVI (73%) • The incidence of apparent cerebral embolism is low (3.6%).

  14. Limitations • Pilot study, small sample size, single site data collection, no multivariate analysis for risk factors. • The incidence of silent and apparent embolism may differ with the Edwards-SAPIEN prosthesis. • DW-MRI following transapical AVI could help elucidating the influence of retrograde passage of the aortic arch and valve as potential embolic sources.

  15. Conclusions • The incidence of clinically silent peri-interventional cerebral embolic lesions is high. • However, in this cohort of 30 patients, the incidence of persistent neurological impairment was low. • Further studies are needed to evaluate independent risk factors for peri-interventional cerebral embolism.

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