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Successful Endovascular Stroke Rescue With Retrieval of an Embolized Calcium Fragment After Transcatheter Aortic Valve Replacement

2014; Lippincott Williams & Wilkins; Volume: 7; Issue: 1 Linguagem: Inglês

10.1161/circinterventions.113.000995

1941-7632

Amir-Ali Fassa, Mikaël Mazighi, Dominique Himbert, Lydia Deschamps, Grégory Ducrocq, Adrian Cheong, Jean‐Pol Depoix, Marie‐Pierre Dilly, Soleiman Alkhoder, Bruno Mourvillier, Alec Vahanian,

Infective Endocarditis Diagnosis and Management

HomeCirculation: Cardiovascular InterventionsVol. 7, No. 1Successful Endovascular Stroke Rescue With Retrieval of an Embolized Calcium Fragment After Transcatheter Aortic Valve Replacement Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBSuccessful Endovascular Stroke Rescue With Retrieval of an Embolized Calcium Fragment After Transcatheter Aortic Valve Replacement Amir-Ali Fassa, MD, Mikael Mazighi, MD, PhD, Dominique Himbert, MD, Lydia Deschamps, MD, Gregory Ducrocq, MD, Adrian P. Cheong, MD, Jean-Pol Depoix, MD, Marie-Pierre Dilly, MD, Soleiman Alkhoder, MD, Bruno Mourvillier, MD and Alec Vahanian, MD Amir-Ali FassaAmir-Ali Fassa From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Mikael MazighiMikael Mazighi From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Dominique HimbertDominique Himbert From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Lydia DeschampsLydia Deschamps From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Gregory DucrocqGregory Ducrocq From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Adrian P. CheongAdrian P. Cheong From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Jean-Pol DepoixJean-Pol Depoix From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Marie-Pierre DillyMarie-Pierre Dilly From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Soleiman AlkhoderSoleiman Alkhoder From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. , Bruno MourvillierBruno Mourvillier From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. and Alec VahanianAlec Vahanian From the Departments of Cardiology (A.-A.F., D.H., G.D., A.P.C., A.V.), Neurology and Stroke Centre (M.M.), Pathology (L.D.), Anesthesiology (J.-P.D., M.-P.D.), Cardiac Surgery (S.A.), and Intensive Care and Infectious Diseases (B.M.), Bichat-Claude-Bernard Hospital, Assistance-Publique-Hôpitaux de Paris, Université Paris VII, Paris, France. Originally published1 Feb 2014https://doi.org/10.1161/CIRCINTERVENTIONS.113.000995Circulation: Cardiovascular Interventions. 2014;7:125–126IntroductionA 90-year-old symptomatic woman with a critical aortic stenosis was referred for transcatheter aortic valve replacement (TAVR). The procedure was performed under locoregional anesthesia from a right femoral approach, with the successful implantation of a 23-mm CoreValve (Medtronic Inc, Minneapolis, MN). Echocardiographic assessment after TAVR showed a mean transprosthetic gradient of 16 mm Hg and trace paravalvular regurgitation. After percutaneous closure of the right femoral artery, the patient suddenly became unresponsive. After prompt intubation, emergency cerebral MRI was performed to assess the presence of reversible ischemia and exclude parenchymal hemorrhage, showing partial occlusion of the right middle cerebral artery with ischemia in the corresponding territory (Figure 1). Conventional cerebral angiography confirmed partial M1-M2 occlusion of the right middle cerebral artery (Figure 2A; Movie I in the Data Supplement). Complete revascularization was achieved using a 4.0×20 mm Solitaire FR retrievable stent (ev3, Irvine, CA) with capture of the embolic material (Figure 2B; Movies II and III in the Data Supplement). The onset-to- reperfusion delay was 150 minutes.Download figureDownload PowerPointFigure 1. A, Diffusion-weighed MRI showing ischemia (faint hypersignal; arrow) in the territory of the right middle cerebral artery. B to D, Magnetic resonance angiography showing partial occlusion of the right middle cerebral artery (arrowhead) on 3-dimensional time-of-flight sequences. C, Close-up of the boxed area in B.Download figureDownload PowerPointFigure 2. A, Conventional cerebral angiography confirming partial M1-M2 occlusion of the right middle cerebral artery (arrowhead). B, Final angiography after retrieval of the embolized debris showing complete patency of the right middle cerebral artery.Histopathologic assessment of the recovered debris (2×6 mm) revealed a calcium fragment that most likely detached from the native aortic valve or the aortic wall (Figure 3).Download figureDownload PowerPointFigure 3. A, Debris recovered during endovascular revascularization. The distance between the lines of the scale on the left is 1 mm. B, Histopathologic assessment (hematoxylin and eosin stained) showing pure calcific material. C and D, High-power magnification of the boxed areas in B.The patient was extubated on the following day. She was fully conscious and orientated, with normal neurological status (modified Rankin Scale score, 0). She had an uneventful recovery and was discharged 9 days after the procedure.DiscussionStroke occurs during or <24 hours of TAVR in ≈3% of cases and is associated with a 12-fold increase in 30-day mortality.1 This complication is presumably related to manipulation of large-bore catheters across the aorta and the calcified aortic valve. A recent histopathologic study on embolized debris captured during TAVR with a filter-based cerebral protection device revealed either thrombotic material or embolized tissue debris derived most likely from the native aortic valve leaflets or aortic wall.2Endovascular intervention for stroke due to catheter- related thrombus during TAVR has been previously reported.3 Although mechanical retrieval of nonthrombotic material from cerebral arteries after acute ischemic stroke has also been described,4 the present case is the first report of retrieval of embolized tissue material presumably originating from the native aortic valve or aortic wall after TAVR. Furthermore, the Solitaire FR retrievable stent has been proven effective in the treatment of acute ischemic stroke, with high rates of successful recanalization and favorable neurological outcomes during follow-up, as well as a low incidence of procedure-related complications (such as distal emboli to a new territory or vessel dissection or perforation).5 In the setting of stroke complicating TAVR, mechanical endovascular revascularization with retrievable stents may be the treatment of choice, because sole intravenous or intra-arterial thrombolysis is contraindicated in fully heparinized patients and may be ineffective in the presence of embolized tissue material.Ultimately, the present case underscores the advantage of locoregional anesthesia during TAVR for immediate diagnosis of neurological events, because interventional rescue could be potentially delayed when patients are intubated and sedated.DisclosuresDr Himbert is a proctor for Medtronic Inc. Dr Vahanian received speaker's fees from Medtronic Inc. The other authors have no conflicts to report.FootnotesThe Data Supplement is available at http://circinterventions.ahajournals.org/lookup/suppl/doi:10.1161/CIRCINTERVENTIONS.113.000995/-/DC1.Correspondence to Amir-Ali Fassa, MD, Department of Cardiology, Bichat Hospital, 46 rue Henri-Huchard, 75018 Paris, France. E-mail [email protected]References1. Stortecky S, Windecker S, Pilgrim T, Heg D, Buellesfeld L, Khattab AA, Huber C, Gloekler S, Nietlispach F, Mattle H, Jüni P, Wenaweser P. Cerebrovascular accidents complicating transcatheter aortic valve implantation: frequency, timing and impact on outcomes.EuroIntervention. 2012; 8:62–70.CrossrefMedlineGoogle Scholar2. Van Mieghem NM, Schipper ME, Ladich E, Faqiri E, van der Boon R, Randjgari A, Schultz C, Moelker A, van Geuns RJ, Otsuka F, Serruys PW, Virmani R, de Jaegere PP. Histopathology of embolic debris captured during transcatheter aortic valve replacement.Circulation. 2013; 127:2194–2201.LinkGoogle Scholar3. Salinas P, Moreno R, Frutos R, Lopez-Sendon JL. Neurovascular rescue for thrombus-related embolic stroke during transcatheter aortic valve implantation.J Am Coll Cardiol Cardiovasc Interv. 2013; 6:981–982.CrossrefGoogle Scholar4. Marder VJ, Chute DJ, Starkman S, Abolian AM, Kidwell C, Liebeskind D, Ovbiagele B, Vinuela F, Duckwiler G, Jahan R, Vespa PM, Selco S, Rajajee V, Kim D, Sanossian N, Saver JL. Analysis of thrombi retrieved from cerebral arteries of patients with acute ischemic stroke.Stroke. 2006; 37:2086–2093.LinkGoogle Scholar5. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO; SWIFT Trialists. 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Anuwatworn A, Raizada A, Kelly S, Stys T, Jonsson O and Stys A (2015) Stroke With Valve Tissue Embolization During Transcatheter Aortic Valve Replacement Treated With Endovascular Intervention, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2015.03.037, 8:9, (1261-1263), Online publication date: 1-Aug-2015. (2020) Mechanical Thrombectomy for Transcatheter Aortic Valve Insertion (TAVI)-Related Periprocedural Stroke: Current Literature and Future Directions, EMJ Interventional Cardiology, 10.33590/emjintcardiol/20-00054 February 2014Vol 7, Issue 1 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.113.000995PMID: 24550532 Manuscript receivedOctober 18, 2013Manuscript acceptedDecember 5, 2013Originally publishedFebruary 1, 2014 KeywordsstrokePDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareCatheter-Based Coronary and Valvular InterventionsCerebrovascular Disease/Stroke