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Association Between TAVR and Early Postprocedural Stroke
Study Questions:
Given >500% growth in transcatheter aortic valve replacement (TAVR) in the United States from 2012 to 2015, has post-TAVR 30-day stroke risk declined as device technology and operator experience have improved?
Methods:
This is a retrospective cohort study of consecutive patients from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies (STS/ACC TVT) Registry who underwent TAVR at 524 US hospitals from November 2011 to May 2017. All patients had a 30-day follow-up assessment. The outcomes were voluntarily reported by study sites and included 30-day rate of stroke, transient ischemic attack (TIA), or either (stroke/TIA). Study outcomes included trend in 30-day stroke/TIA over time and the association of post-TAVR 30-day stroke with mortality.
Results:
The study cohort included 101,430 TAVR patients. By day 30, 2,290 patients had had a stroke/TIA (2.3%; 95% confidence interval [CI], 2.2-2.4%). Patients with 30-day stroke were more likely to have prior stroke or TIA, peripheral arterial disease, hypertension, porcelain aorta, and/or carotid stenosis. The median time to stroke/TIA was 2 days (interquartile range, 1-5 days) after TAVR. No significant increase or decrease in post-TAVR stroke/TIA rate was seen over time (p for trend = 0.22). There was no difference in the 30-day stroke rate between sites with <100 or >100 TAVR cases. Compared to patients without stroke, patients with stroke within 30 days after TAVR had higher 30-day mortality (3.7% vs. 16.7%; adjusted hazard ratio, 6.1; 95% CI, 5.4-6.8).
Conclusions:
The rate of post-TAVR 30-day stroke remained stable from November 2011 to May 2017, despite advances in technology and improved operator experience over those years.
Perspective:
Given that neurologic events were self-reported in this registry, a 30-day stroke/TIA rate of 2.3% may represent an underestimate. This study suggests that operator experience and site volume may not have a beneficial effect on post-TAVR 30-day stroke/TIA rate. However, given that patients with cardiovascular risk factors (e.g., porcelain aorta and carotid stenosis) were more likely to have post–TAVR stroke than those without risk factors, the longitudinal stability in TIA/stroke rate may be a function of proceduralists taking “sicker” patients for TAVR over time as comfort with the procedure has increased. Not surprisingly, post-TAVR 30-day stroke was associated with 30-day mortality.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Hypertension
Keywords: Carotid Stenosis, Cardiac Surgical Procedures, Heart Valve Diseases, Heart Valve Prosthesis, Hypertension, Ischemic Attack, Transient, Peripheral Arterial Disease, Risk Factors, Secondary Prevention, Stroke, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement, Vascular Diseases
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