Stroke
2012; Lippincott Williams & Wilkins; Volume: 126; Issue: 25 Linguagem: Eslovaco
10.1161/circulationaha.112.149492
ISSN1524-4539
AutoresStefan Stortecky, Stephan Windecker,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 126, No. 25Stroke Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBStrokeAn Infrequent but Devastating Complication in Cardiovascular Interventions Stefan Stortecky, MD and Stephan Windecker, MD Stefan StorteckyStefan Stortecky From the Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland. and Stephan WindeckerStephan Windecker From the Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland. Originally published18 Dec 2012https://doi.org/10.1161/CIRCULATIONAHA.112.149492Circulation. 2012;126:2921–2924Stroke is a dreadful complication of cardiovascular interventions owing to the clinical manifestations of neurological deficits and the impact on prognosis (Table). Whereas the risk of cerebrovascular events (CVE) is exceedingly low among patients undergoing percutaneous coronary intervention (0.3%),1 it does range from 1.2% to 3.8% among patients undergoing isolated coronary artery bypass grafting,1,2 and is as high as 9.7% among patients undergoing double or triple valve surgery.2 Although transcatheter aortic valve implantation (TAVI) shares many features of a minimal-invasive treatment with other percutaneous techniques, this advantage does not extend to the risk of stroke, which occurs with a frequency of 2.7% to 4.2%.3 In the randomized Placement of Aortic Transcatheter Valves (PARTNER) Trial cohort 1A, rates of stroke and transient ischemic attack were higher among patients undergoing TAVI compared with surgical aortic valve replacement at 30 days (4.6% versus 2.4%; P=0.12), 1 year (8.7% versus 4.3%; P=0.03), and 2 years (11.2% versus 6.5%; P=0.05) of follow-up.4 Similarly, TAVI was associated with an increased risk of CVE compared with medical treatment in the randomized PARTNER 1B study at 30 days (6.7% versus 1.7%, P=0.02), 1 year (11.2 versus 5.5%, P=0.06) and 2 years of follow-up (13.8% versus 5.5%, P=0.01).5Table. Risk of Cerebrovascular Events With Cardiovascular InterventionsRisk of Stroke (%)Surgical procedures Carotid endarterectomy2.3 Coronary artery bypass graft surgery1.2–3.8 Thoracic aortic surgery6.1 Aortic valve surgery1.5–4.0 Mitral valve surgery1.1–1.6 Combined valve and coronary artery bypass graft surgery3.7–7.4 Double or triple valve surgery5.4–9.7Interventional procedures Percutaneous coronary intervention0.2–0.3 Carotid artery stenting4.1 Transcatheter aortic valve implantation2.7–4.2Article see p 3041The awareness of this adverse event has been heightened in the recent update of standardized end point definitions for TAVI issued by the Valve Academic Research Consortium.6 CVE are no longer stratified into transient ischemic attack and stroke, but rather into disabling and nondisabling stroke according to the modified Rankin scale. Moreover, rigorous stroke assessment has become an integral part of ongoing trials comparing TAVI with surgical aortic valve replacement among intermediate-risk patients by contributing to the primary end point (composite of death and disabling stroke) and demanding systematic neurological examinations before and after the procedure.In this issue of Circulation, Nombela-Franco and colleagues7 provide an in-depth analysis of the timing and predictive factors of CVE in 1 of the largest TAVI cohorts studied to date. In a concerted effort of 5 esteemed institutions, individual patient data from 1061 consecutive patients undergoing TAVI were compiled using similar outcome definitions, treatment, and follow-up protocols. Events were categorized as acute when occurring within the first 24 hours after the procedure, as subacute when observed between the first postoperative day and 30 days of follow-up, and as late for any event occurring beyond 30 days after the procedure. The cumulative incidence of CVE of 8.4% (1 in 12 patients undergoing TAVI) during a median follow-up of 1 year is concerning, particularly because only clinically overt events were ascertained in the absence of systematic neurological evaluation before or after the procedure. Notwithstanding, the authors offer important insights into the timing and prediction of CVE, which offer valuable guidance to clinicians performing TAVI.Acute Risk of CVEThe majority of CVE (54%) in the present study occurred during the acute phase after TAVI (Figure). An embolic mechanism as cause for acute CVE is plausible and supported by MRI studies detecting clinically silent, new intracranial lesions in the majority of patients undergoing TAVI.8 Retrograde passage of a stenosed aortic valve during diagnostic catheterization has been shown to result in new focal cerebral lesions using MRI in 22% of patients.9 In addition, balloon aortic valvuloplasty leads to fracture and denudation of deposits of calcium, which do not only become friable and therefore prone to embolization but also exposed to the circulation with activation of platelets and the coagulation cascade with the attendant risk of thromboembolic complications. Moreover, advancement of the delivery catheter into the aortic annulus and deployment of the valve prosthesis may cause embolization of particulate and calcified debris from previously denudated calcium deposits. Using transcranial Doppler ultrasonography, Erdös et al10 and Kahlert et al11 reported on loads of high intensity transient signals, as surrogate marker for microembolization during different stages of the implantation of self- and balloon-expandable TAVI prostheses. Whereas the balloon-expandable Edwards Sapien prosthesis elicited the highest load of high intensity transient signals during positioning of the valve in the annulus, the self-expanding Medtronic CoreValve prosthesis caused most high intensity transient signals during the process of valve deployment.Download figureDownload PowerPointFigure. Risk of cerebrovascular events according to time after transcatheter aortic valve implantation (green line indicates patients undergoing transcatheter aortic valve implantation [TAVI]; red line displays the risk of an age-, sex-, and risk factor–matched population). AFib indicates atrial fibrillation; NOAFib, new onset atrial fibrillation; and (N)OAC, (novel) oral anticoagulants.A minimal or no-touch technique avoiding any interference with the ascending aorta as well as sparing predilatation of the stenosed aortic valve before prosthesis delivery has been proposed to reduce the risk of periprocedural stroke.12 Moreover, improvements in the design of delivery catheters, such as enhanced steerability, deflectable catheters, and low cross-sectional profiles, will reduce contact with vulnerable lesions.Repeat dilatation of the prosthesis to resolve underexpansion of the valve or residual paravalvular aortic regurgitation was associated with a 2.5-fold increased risk of CVE in the present study. An even greater risk (4-fold) during the acute period was related to dislodgement or embolization of the valve prosthesis. This observation suggests that meticulous planning of the procedure in terms of device and size selection is instrumental to avoid valve malposition and paravalvular aortic regurgitation and related CVE. Recent advances in valve technology, including fully repositionable valve types, aim at more precise alignment of the valve prosthesis within the native annulus, which should reduce the risk of valve embolization as well as paravalvular regurgitation. In addition, these devices may allow for less traumatic implantation with accelerated endothelialization attenuating activation of platelets and coagulation. Mechanical cerebral protection devices are yet another approach to reduce periprocedural cerebral embolism during TAVI. Currently, 3 different cerebral protection devices are investigated in ongoing studies, all of which consist of a filter membrane placed either in the aortic arch to deflect particulate debris toward the descending aorta (SMT Embolic Protection Device, Embrella Deflector), or in the large supraaortic branches to filter and retrieve embolized particles from the cerebral circulation (Claret Filter Device). Finally, thrombin-specific anticoagulants may improve the level and consistency of anticoagulation during the procedure, while reducing the risk of bleeding complications.13Subacute Risk of CVENew onset of atrial fibrillation (NOAF) was observed in 12% of patients undergoing TAVI in the study by Nombela-Franco and emerged as single, independent predictor of CVEs during the subacute phase after TAVI (Figure). Atrial fibrillation is a well-known complication after cardiac surgery, and its pathophysiological mechanisms have been related to consequences of the extracorporeal circulation and associated perioperative inflammatory reactions. NOAF affects up to two thirds of patients after open heart surgery and is highest among patients undergoing valve surgery.14 Patients with NOAF after cardiac surgery are more likely to experience CVE, more frequently undergo permanent pacemaker implantation, and require a longer stay in the intensive care unit and in the hospital overall, all of which result in a cost increase of up to $11 000 per patient.14 Considering procedural differences between surgical aortic valve replacement and TAVI, it is somewhat surprising that NOAF has been reported in up to 32% of patients within the first 30 days after TAVI.15 However, patients undergoing TAVI are typically octogenarians with a higher baseline risk for atrial fibrillation, which may further be precipitated by severe aortic stenosis and underlying diastolic dysfunction. Transapical access is another predictor for NOAF likely related to pericardial dissection and subsequent inflammation. The latter may explain why transapical access has failed to translate into a lower risk of periprocedural stroke. Indeed, neither imaging studies using diffusion weighted MRI nor clinical studies in large patient cohorts showed differences in the number of new intracranial lesions or clinically apparent stroke between patients undergoing transapical as compared with transfemoral TAVI.16Prevention of NOAF and its sequelae should entail careful screening of patients at risk including assessment of a history of atrial fibrillation, echocardiographic evidence of enlarged atria, diastolic dysfunction, and presence of thrombi in the left atrium or atrial appendage. Procedural considerations include the avoidance of triggers of NOAF by minimizing myocardial injury, careful maintenance of electrolyte balance, and aggressive treatment of volume overload. Finally, pharmacological measures such as β-blockers (in the absence of atrioventricular conduction disturbances), amiodarone, angiotensin converting enzyme inhibitors, and angiotensin II receptor antagonists may be considered in patients at increased risk for atrial fibrillation. If NOAF is encountered after TAVI, patients require therapeutic anticoagulation, and restoration of sinus rhythm by pharmacological or electric conversion has been shown successful in the vast majority of patients.Late Risk of CVEChronic atrial fibrillation has emerged as 1 of the principal predictors of late and cumulative CVE after TAVI. Peripheral vascular and previous cerebrovascular disease, as markers of global atherosclerotic burden, were identified as additional independent predictors for the occurrence of late CVE. The frequency and predictors of late CVE point to the spontaneous risk of stroke among elderly patients undergoing TAVI rather than to a risk related to the implanted prosthesis (Figure). The prevalence of stroke is age-dependent, with rates as high as 15% among people ≥80 years of age, and several risk factors, including female sex, arterial hypertension, diabetes mellitus, left ventricular hypertrophy, and smoking, contribute to the spontaneous risk of CVE.17 Aggressive risk factor modification, including treatment of lipid abnormalities and arterial hypertension, are important treatment goals. In addition, the appropriate antiplatelet and antithrombotic treatment after TAVI remains yet to be defined, requiring a careful balance between prevention of ischemic and bleeding events. Among patients with atrial fibrillation, anticoagulation by means of vitamin K antagonists or novel oral anticoagulants should be implemented, while exclusion of the left atrial appendage by means of percutaneous techniques may be considered in patients at increased risk for bleeding.CVEs after TAVI adversely impact prognosis, and major stroke in the present study was associated with early and late mortality. However, outcomes may be improved by rapid diagnosis and timely installment of therapy. As a result of the minimally invasive nature of the procedure, TAVI can be performed under light sedation without general anesthesia, which facilitates early recognition of neurological deficits, and frequent neurological check-ups should be extended during postprocedural care. Stroke, particularly during the periprocedural period after TAVI, is amenable to treatment, and dedicated stroke teams can provide immediate access to brain imaging and interventional stroke treatment including intra-arterial thrombolysis or catheter-based recanalization and thrombus extraction, which may favorably impact on prognosis.The work of Nombela-Franco and colleagues is an important contribution to our understanding of the pathogenesis of stroke after TAVI and will give rise to multiple hypotheses stimulating research in preventive strategies. Although stroke will always remain a nuisance in cardiovascular interventions, careful attention to technical details during TAVI as well as optimal medical treatment after the intervention will help to mitigate this adverse event.DisclosuresDr Windecker has received research contracts to the institution from Abbott, Boston Scientific, Biosensors, Biotronik, Cordis, Edwards Lifesciences, Medtronic, and St. Jude and grant support from the Swiss National Science Foundation (SNF Grant 32003B_135807). Dr Stortecky reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Stephan Windecker, MD, Department of Cardiology, Bern University Hospital, 3010 Bern, Switzerland. E-mail stephan.[email protected]chReferences1. Palmerini T, Biondi-Zoccai G, Reggiani LB, Sangiorgi D, Alessi L, De Servi S, Branzi A, Stone GW. Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention. J Am Coll Cardiol. 2012; 60:798–805.CrossrefMedlineGoogle Scholar2. Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Onnasch JF, Metz S, Falk V, Mohr FW. Stroke after cardiac surgery. Ann Thorac Surg. 2003; 75:472–478.CrossrefMedlineGoogle Scholar3. Eggebrecht H, Schmermund A, Voigtlander T, Kahlert P, Erbel R, Mehta RH. Risk of stroke after transcatheter aortic valve implantation (TAVI). EuroIntervention. 2012; 8:129–138.CrossrefMedlineGoogle Scholar4. Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, Fontana GP, Dewey TM, Thourani VH, Pichard AD, Fischbein M, Szeto WY, Lim S, Greason KL, Teirstein PS, Malaisrie SC, Douglas PS, Hahn RT, Whisenant B, Zajarias A, Wang D, Akin JJ, Anderson WN, Leon MB. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012; 366:1686–1695.CrossrefMedlineGoogle Scholar5. Makkar RR, Fontana GP, Jilaihawi H, Kapadia S, Pichard AD, Douglas PS, Thourani VH, Babaliaros VC, Webb JG, Herrmann HC, Bavaria JE, Kodali S, Brown DL, Bowers B, Dewey TM, Svensson LG, Tuzcu M, Moses JW, Williams MR, Siegel RJ, Akin JJ, Anderson WN, Pocock S, Smith CR, Leon MB. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012; 366:1696–1704.CrossrefMedlineGoogle Scholar6. Kappetein AP, Head SJ, Genereux P, Piazza N, van Mieghem NM, Blackstone EH, Brott TG, Cohen DJ, Cutlip DE, van Es GA, Hahn RT, Kirtane AJ, Krucoff MW, Kodali S, Mack MJ, Mehran R, Rodes-Cabau J, Vranckx P, Webb JG, Windecker S, Serruys PW, Leon MB. Updated standardized endpoint definitions for transcatheter aortic valve implantation. J Am Coll Cardiol. 2012; 60:1438–1454.CrossrefMedlineGoogle Scholar7. Nombela-Franco L, Webb JG, de Jaegere PP, Toggweiler S, Nuis RJ, Dager AE, Amat-Santos IJ, Cheung A, Ye J, Binder RK, van der Boon RM, Van Mieghem N, Benitez L, Pérez S, Lopez J, San Roman JA, Doyle D, DeLarochelliére R, Urena M, Leipsic J, Dumont E, Rodes-Cabau J. Timing, predictive factors and prognostic value of cerebrovascular events in a large cohort of patients undergoing transcatheter aortic valve implantation. Circulation. 2012; 126:3041–3053.LinkGoogle Scholar8. Kahlert P, Knipp SC, Schlamann M, Thielmann M, Al-Rashid F, Weber M, Johansson U, Wendt D, Jakob HG, Forsting M, Sack S, Erbel R, Eggebrecht H. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation. Circulation. 2010; 121:870–878.LinkGoogle Scholar9. Omran H, Schmidt H, Hackenbroch M, Illien S, Bernhardt P, von der Recke G, Fimmers R, Flacke S, Layer G, Pohl C, Luderitz B, Schild H, Sommer T. Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis. Lancet. 2003; 361:1241–1246.CrossrefMedlineGoogle Scholar10. Erdoes G, Basciani R, Huber C, Stortecky S, Wenaweser P, Windecker S, Carrel T, Eberle B. Transcranial Doppler-detected cerebral embolic load during transcatheter aortic valve implantation. Eur J Cardiothorac Surg. 2012; 41:778–783, discussion 783–774.CrossrefMedlineGoogle Scholar11. Kahlert P, Al-Rashid F, Dottger P, Mori K, Plicht B, Wendt D, Bergmann L, Kottenberg E, Schlamann M, Mummel P, Holle D, Thielmann M, Jakob HG, Konorza T, Heusch G, Erbel R, Eggebrecht H. Cerebral embolization during transcatheter aortic valve implantation. Circulation. 2012; 126:1245–1255.LinkGoogle Scholar12. Grube E, Naber C, Abizaid A, Sousa E, Mendiz O, Lemos P, Kalil Filho R, Mangione J, Buellesfeld L. Feasibility of transcatheter aortic valve implantation without balloon pre-dilation. J Am Coll Cardiol Cardiovasc Interv. 2011; 4:751–757.CrossrefGoogle Scholar13. Dangas G. Efficacy and safety of bivalirudin compared to unfractionated heparin among patients undergoing balloon aortic valvuloplasty. J Am Coll Cardiol. 2011; 58:B217.CrossrefGoogle Scholar14. Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern Med. 2001; 135:1061–1073.CrossrefMedlineGoogle Scholar15. Amat-Santos IJ, Rodes-Cabau J, Urena M, DeLarochelliere R, Doyle D, Bagur R, Villeneuve J, Cote M, Nombela-Franco L, Philippon F, Pibarot P, Dumont E. Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation. J Am Coll Cardiol. 2012; 59:178–188.CrossrefMedlineGoogle Scholar16. Rodes-Cabau J, Dumont E, Boone RH, Larose E, Bagur R, Gurvitch R, Bedard F, Doyle D, De Larochelliere R, Jayasuria C, Villeneuve J, Marrero A, Cote M, Pibarot P, Webb JG. Cerebral embolism following transcatheter aortic valve implantation. J Am Coll Cardiol. 2011; 57:18–28.CrossrefMedlineGoogle Scholar17. Wolf PA, D'Agostino RB, Belanger AJ, Kannel WB. Probability of stroke: a risk profile from the Framingham Study. Stroke. 1991; 22:312–318.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Camaj A, Razuk V and Dangas G (2022) Antithrombotic Strategies in Valvular and Structural Heart Disease Interventions Interventional Cardiology, 10.1002/9781119697367.ch50, (529-538), Online publication date: 3-Jun-2022. Iervolino A, Singh S, Nappi P, Bellomo F, Nappi F and Liberale L (2021) Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review, BioMed Research International, 10.1155/2021/3973924, 2021, (1-26), Online publication date: 26-May-2021. Greco A and Capodanno D (2020) Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status, Interventional Cardiology Review, 10.15420/icr.2019.24, 15 Trimaille A, Marchandot B, Park S, Schini-Kerth V and Morel O (2020) The difficult balance between thrombosis and bleeding after transcatheter aortic valve replacement: A translational review, Archives of Cardiovascular Diseases, 10.1016/j.acvd.2019.12.003, 113:4, (263-275), Online publication date: 1-Apr-2020. Haiman G, Nazif T, Moses J, Ashkenazi A, Margolis P and Lansky A (2020) Reduction of Cerebral Emboli: In vitro Study with a Novel Cerebral Embolic Protection Device, Medical Devices: Evidence and Research, 10.2147/MDER.S234961, Volume 13, (67-73) Power D, Guedeney P and Dangas G (2019) Adjunct Pharmacotherapy After Transcatheter Aortic Valve Replacement, Interventional Cardiology Clinics, 10.1016/j.iccl.2019.05.003, 8:4, (357-371), Online publication date: 1-Oct-2019. Greco A, Capranzano P, Barbanti M, Tamburino C and Capodanno D (2019) Antithrombotic pharmacotherapy after transcatheter aortic valve implantation: an update, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2019.1632189, 17:7, (479-496), Online publication date: 3-Jul-2019. Guedeney P, Mehran R, Collet J, Claessen B, ten Berg J and Dangas G (2019) Antithrombotic Therapy After Transcatheter Aortic Valve Replacement, Circulation: Cardiovascular Interventions, 12:1, Online publication date: 1-Jan-2019. Franzone A and Stortecky S (2019) Embolic Protection Devices for Transcatheter Aortic Valve Implantation Transcatheter Aortic Valve Implantation, 10.1007/978-3-030-05912-5_30, (363-375), . Windecker S, Franzone A and Pilgrim T (2018) Deciphering the Unknowns of Stroke After Aortic Valve Interventions, Journal of the American College of Cardiology, 10.1016/j.jacc.2018.09.015, 72:20, (2427-2430), Online publication date: 1-Nov-2018. Flueckiger P, Singleton M, Vasu S and Zhao D (2017) Bioprosthetic tricuspid valve thrombosis: Percutaneous PFO closure to improve hypoxia and respiratory failure, Catheterization and Cardiovascular Interventions, 10.1002/ccd.27217, 92:5, (993-997), Online publication date: 1-Nov-2018. Hamandi M, Farber A, Tatum J, Brinkman W, Brown D, Lawrence M and Mack M (2018) Acute stroke intervention after transcatheter aortic valve replacement, Baylor University Medical Center Proceedings, 10.1080/08998280.2018.1499294, 31:4, (490-492), Online publication date: 2-Oct-2018. Erdoes G, Rummel C, Basciani R, Verma R, Carrel T, Banz Y, Eberle B and Schroth G (2018) Limitations of Current Near-Infrared Spectroscopy Configuration in Detecting Focal Cerebral Ischemia During Cardiac Surgery: An Observational Case-Series Study, Artificial Organs, 10.1111/aor.13150, 42:10, (1001-1009), Online publication date: 1-Oct-2018. Abubakar H, Yassin A, Akintoye E, Bakhit K, Pahuja M, Shokr M, Lieberman R and Afonso L (2018) Financial Implications and Impact of Pre-existing Atrial Fibrillation on In-Hospital Outcomes in Patients Who Underwent Transcatheter Aortic Valve Implantation (from the National Inpatient Database), The American Journal of Cardiology, 10.1016/j.amjcard.2018.02.052, 121:12, (1587-1592), Online publication date: 1-Jun-2018. Lansky A, Messé S, Brickman A, Dwyer M, Bart van der Worp H, Lazar R, Pietras C, Abrams K, McFadden E, Petersen N, Browndyke J, Prendergast B, Ng V, Cutlip D, Kapadia S, Krucoff M, Linke A, Scala Moy C, Schofer J, van Es G, Virmani R, Popma J, Parides M, Kodali S, Bilello M, Zivadinov R, Akar J, Furie K, Gress D, Voros S, Moses J, Greer D, Forrest J, Holmes D, Kappetein A, Mack M and Baumbach A (2017) Proposed Standardized Neurological Endpoints for Cardiovascular Clinical Trials, European Heart Journal, 10.1093/eurheartj/ehx037, 39:19, (1687-1697), Online publication date: 14-May-2018. Lansky A, Messé S, Brickman A, Dwyer M, van der Worp H, Lazar R, Pietras C, Abrams K, McFadden E, Petersen N, Browndyke J, Prendergast B, Ng V, Cutlip D, Kapadia S, Krucoff M, Linke A, Moy C, Schofer J, van Es G, Virmani R, Popma J, Parides M, Kodali S, Bilello M, Zivadinov R, Akar J, Furie K, Gress D, Voros S, Moses J, Greer D, Forrest J, Holmes D, Kappetein A, Mack M and Baumbach A (2017) Proposed Standardized Neurological Endpoints for Cardiovascular Clinical Trials, Journal of the American College of Cardiology, 10.1016/j.jacc.2016.11.045, 69:6, (679-691), Online publication date: 1-Feb-2017. Windecker S, Tijssen J, Giustino G, Guimarães A, Mehran R, Valgimigli M, Vranckx P, Welsh R, Baber U, van Es G, Wildgoose P, Volkl A, Zazula A, Thomitzek K, Hemmrich M and Dangas G (2017) Trial design: Rivaroxaban for the prevention of major cardiovascular events after transcatheter aortic valve replacement: Rationale and design of the GALILEO study, American Heart Journal, 10.1016/j.ahj.2016.10.017, 184, (81-87), Online publication date: 1-Feb-2017. Schoos M, Capodanno D and Dangas G (2016) Antithrombotic Strategies in Valvular and Structural Heart Disease Interventions Interventional Cardiology, 10.1002/9781118983652.ch53, (507-516) Imran Ghare M and Lansky A (2017) Understanding neurologic complications following TAVI, Interventional Cardiology Review, 10.15420/icr.2017:25:1, 13:01, (27), . Seeger J, Gonska B, Rodewald C, Rottbauer W and Wöhrle J (2017) Apixaban in Patients With Atrial Fibrillation After Transfemoral Aortic Valve Replacement, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2016.10.023, 10:1, (66-74), Online publication date: 1-Jan-2017. Khera S, Ahmad H, Tang G and Bapat V (2017) Transcatheter Management of TAVI-Associated Paravalvular Leak Transcatheter Paravalvular Leak Closure, 10.1007/978-981-10-5400-6_10, (153-162), . Dangas G, Weitz J, Giustino G, Makkar R and Mehran R (2016) Prosthetic Heart Valve Thrombosis, Journal of the American College of Cardiology, 10.1016/j.jacc.2016.09.958, 68:24, (2670-2689), Online publication date: 1-Dec-2016. Kleiman N, Maini B, Reardon M, Conte J, Katz S, Rajagopal V, Kauten J, Hartman A, McKay R, Hagberg R, Huang J, Popma J, Adams D, Ad N, Aharonian V, Anderson W, Applegate R, Bafi A, Bajwa T, Bakhos M, Ball S, Batra S, Beohar N, Brachinsky W, Brinster D, Brown J, Byrne J, Byrne T, Casale A, Caskey M, Chawla A, Cohen H, Coselli J, Costa M, Cheatham J, Chetcuti S, Crestanello J, Davis T, Michael Deeb G, Diez J, Dauerman H, Elefteriades J, Fail P, Feinberg E, Fontana G, Forrest J, Galloway A, Giacomini J, Gleason T, Guadiani V, Harrison J, Hebeler R, Heimansohn D, Heiser J, Heller L, Henry S, Hermiller J, Hockmuth D, Hughes G, Joye J, Kafi A, Kar B, Khabbaz K, Kipperman R, Kliger C, Kon N, Lamelas J, Lee J, Leya F, Londono J, Macheers S, Mangi A, de Marchena E, Markowitz A, Matthews R, Merhi W, Mumtaz M, O'Hair D, Petrossian G, Pfeffer T, Raybuck B, Resar J, Robbins M, Robbins R, Robinson N, Ring M, Salerno T, Schreiber T, Schmoker J, Sharma S, Siwek L, Skelding K, Slater J, Starnes V, Stoler R, Subramanian V, Tadros P, Thompson C, Waksman R, Watson D, Yakubov S, Zhao D and Zorn G (2016) Neurological Events Following Transcatheter Aortic Valve Replacement and Their Predictors, Circulation: Cardiovascular Interventions, 9:9, Online publication date: 1-Sep-2016. Hemmrich M, Peterson E, Thomitzek K and Weitz J (2017) Spotlight on unmet needs in stroke prevention: The PIONEER AF-PCI, NAVIGATE ESUS and GALILEO trials, Thrombosis and Haemostasis, 10.1160/TH16-06-0487, 116:S 02, (S33-S40), . Giustino G and Dangas G (2015) Stroke prevention in valvular heart disease: from the procedure to long-term management, EuroIntervention, 10.4244/EIJV11SWA7, 14:W, (W26-W31), Online publication date: 1-Sep-2015. Mastoris I, Schoos M, Dangas G and Mehran R (2014) Stroke After Transcatheter Aortic Valve Replacement: Incidence, Risk Factors, Prognosis, and Preventive Strategies, Clinical Cardiology, 10.1002/clc.22328, 37:12, (756-764), Online publication date: 1-Dec-2014. Ghanem A, Kocurek J, Sinning J, Weber M, Hammerstingl C, Wagner M, Vasa-Nicotera M, Grube E, Werner N and Nickenig G (2014) Novel approaches for prevention of stroke related to transcatheter aortic valve implantation, Expert Review of Cardiovascular Therapy, 10.1586/14779072.2013.837696, 11:10, (1311-1320), Online publication date: 1-Oct-2013. Kahlert P, Al-Rashid F, Döttger P, Mori K, Plicht B, Wendt D, Bergmann L, Kottenberg E, Schlamann M, Mummel P, Holle D, Thielmann M, Jakob H, Heusch G, Erbel R and Eggebrecht H (2013) Response to Letters Regarding Article, "Cerebral Embolization During Transcatheter Aortic Valve Implantation: A Transcranial Doppler Study", Circulation, 127:18, (e591-e592), Online publication date: 7-May-2013. December 18, 2012Vol 126, Issue 25 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.149492PMID: 23248061 Originally publishedDecember 18, 2012 Keywordsaortic valveEditorialsstrokePDF download Advertisement SubjectsCerebrovascular Disease/StrokeIschemic Stroke
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