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Neurological Complications After TAVR vs. SAVR in Intermediate-Risk Patients
Study Questions:
How do neurologic events differ after transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR)?
Methods:
This is a post-hoc analysis of the SURTAVI trial, which enrolled patients with severe symptomatic aortic stenosis at intermediate surgical risk (30-day surgical mortality risk of 3-15%) and randomized patients 1:1 to TAVR versus SAVR. Patients underwent neurologic assessment at baseline, post-procedure, discharge, 30 days, 6 months, and 12 months. Neurologic endpoints included stroke, transient ischemic attack (TIA), and encephalopathy. Neurologic endpoints were classified as occurring early (0-30 days) or late (31-365 days) post-procedure.
Results:
The TAVR group included 864 patients and the SAVR group included 796 patients. Early strokes were more common than late strokes in both the TAVR (63.6% early) and SAVR (79.6% early) groups. Fewer early strokes occurred after TAVR than after SAVR (3.3% vs. 5.4%; p = 0.031). The risk of early stroke was lower across all subgroups (e.g., male/female, BMI ≤/>30, diabetes yes/no, coronary artery disease yes/no) in the TAVR group compared to the SAVR group. No difference was observed between the groups in early TIA. Early encephalopathy was less frequent after TAVR than after SAVR (1.6% vs. 7.8%; p < 0.001). Whereas patients with no early neurologic events had 1-year mortality rates of 4.5% and 3.9% in the TAVR and SAVR groups, respectively, patients with early stroke had 1-year mortality rates of 17.9% and 14.0% and patients with early encephalopathy had 1-year mortality rates of 21.4% and 17.0%. No differences in the incidence of late stroke, late TIA, or late encephalopathy were observed between the TAVR and SAVR groups.
Conclusions:
The highest risk of stroke in TAVR and SAVR is early (<30 days) post-procedure. Early stroke and early encephalopathy are less common after TAVR than after SAVR. Compared to patients without early neurologic events, patients with early neurologic events had higher 1-year mortality in both groups.
Perspective:
Stroke in the 30 days after TAVR or SAVR is a relatively uncommon event (<6% in SURTAVI patients). However, early stroke is a serious complication of valve replacement that is associated with higher 1-year mortality. Early stroke appears less common after TAVR compared to SAVR. The results of this study support the use of TAVR as an alternative to SAVR in patients with severe aortic stenosis who are at intermediate surgical risk.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Coronary Artery Disease, Diabetes Mellitus, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Hypertensive Encephalopathy, Ischemic Attack, Transient, Neurologic Manifestations, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement, Vascular Diseases
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