Supplemental Figure 1: Forest Plot of Single center Experience: A. Showing the individual and
Pooled Event Rates for stroke (30 day/inhospital) using the Transfemoral (TF) and Transapical
(TA) approach for TAVR. B. Showing the Odds Ratio (OR) for stroke, comparing the Transfemoral
and Transapical approach.
Supplemental Figure 2: Forest Plot of Single center Experience: A. Showing the individual and
Pooled Event Rates for stroke (30 day/inhospital) using the CoreValve (TF) or Edwards Valve (ES)
for TAVR. B. Showing the Odds Ratio (OR) for stroke, comparing the CoreValve and Edwards
Valve.
Supplemental Figure 3: Forest Plot A. Showing the Odds Ratio (OR) for stroke, comparing TAVR
and SAVR in high surgical risk patients B. Showing the Odds Ratio (OR) for stroke, comparing
TAVR and SAVR in intermediate surgical risk patients. Surgical Aortic Valve Replacement (SAVR)
and TAVR (Transcatheter Aortic Valve Replacement)
Supplemental Figure 4: Forest Plot of Stroke after TAVR using the Transfemoral approach: A.
Showing the individual and Pooled Event Rates for stroke (30 day/inhospital) using the
CoreValve or Edwards Valve in Multicenter studies B. Showing the individual and Pooled Event
Rates for stroke (30 day/inhospital) using the CoreValve or Edwards Valve in Single center
studies.
Supplemental Figure 5: Forest Plot of Stroke after TAVR using the Edwards Valve: A. Showing
the individual and Pooled Event Rates for stroke (30 day/inhospital) using the Transfemoral (TF)
and Transapical (TA) approach in Multicenter studies B. . Showing the individual and Pooled
Event Rates for stroke (30 day/inhospital) using the Transfemoral (TF) and Transapical (TA)
approach in Single center studies.
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Registry Name
Locations Centers (N)
Study period
Study
(N)
Approach (%)
Valve (%) Publication Type
18F EEe1,e2 Europe 51 2007-2009 1483 TF (100) 18F (100) Conference
ADVANCEe3 Worldwide 44 2010-2011 879 TF (100) 18F (100) Conference
ANZ CoreValvee4
Australia/NZ
10 2010-2011 428 TF (100) 18F (100) Conference
ANZ Sourcee5 Australia/NZ
8 2008-2009 130 TF (52)
TA (48)
Sa (100) Conference
Asia TAVIe6 Asia 14 2009-2013 253 TF (78)
TA (17)
MC (52)
Sa (48)
Conference
Belgiume7 Belgium 15 2008-2010 328 TF (70)
TA (30)
18F (43)
Sa (57)
Publication
Brazile8 Brazil 18 2008-2013 418 TF (96) MC (86)
XT (14)
Conference
Canadae9,e10 Canada 6 2005-2009 339 TF (48)
TA (52)
CE (17)
Sa (81) XT (2)
Publication
FRANCEe11 France 16 2009-2009 232 TF (66)
TA (29)
18F (32)
Sa (68)
Publication
FRANCE 2e12 France 34 2010-2011 2419 TF (73)
TA (18)
18F (33)
Sa (67)
Publication
GARYe13 Germany 69 2011-2011 3875 TF (65)
TA (35)
18F (47)
Sa (53)
Conference
Greecee14 Greece 4 2009-2011 126 TF (100) 18F (54)
XT (46)
Publication
Ibero-Americane15
Europe/South America
43 2007-2012 1170 TF (95) 18F (100) Publication
I-TAe16 Italy 21 2008-2012 774 TA (100) Sa (65)
XT (35)
Publication
Italian CoreValvee17
Italy 14 2007-2009 659 TF (100) 18F (100) Publication
PARTNER I Cohort Ae18
USA 25 2007-2009 348 TF (71)
TA (29)
Sa (100) Publication
PARTNER I Cohort Be19
USA 21 2007-2009 171 TF (100) Sa (100) Publication
PARTNER IIe20 USA 28 2011-2012 560 TF (100) Sa (49)
XT (51)
Conference
PREVAIL TAe21 Europe 12 2009-2010 150 TA (100) XT (100) Publication
EORP/TCVTe22 Europe 137 2011-2012 4547 TF (74)
TA (16)
18F (43)
XT (57)
Publication
SOURCEe23 Europe 37 2007-2009 2307 TF (40)
TA (60)
Sa (100) Conference
SOURCE XTe24 Europe 94 2010-2011 2600 TF (63)
TA (33)
XT (100) Conference
U.K TAVIe25 U.K 25 2007-2009 870 TF (69)
TA (27)
MC (52)
Sa (48)
Publication
STS/ACC TVT Registrye26
USA 250 2011-2013 8075 TF (64%)
TA (29%)
Sa (100) Publication
CoreValve Extreme Riske27
USA 40 2010-2013 487 TF (100%) 18F (100) Conference
Supplemental Table 1: Included Multi center studies. TF= Transfemoral , TA= Transapical, 18F =18 F CoreValve, MC= Medtronics CoreValve,Sa = Edwards Sapien Valve, XT = Edwards Sapient XT. (Supplemental e reference 1-27)
Single center location
Country Study period Study N Approach (%) Valve used (%) Publication type
Quebec Citye28 Canada NA 211 TF (15.8)
TA (84.2)
ES(100) Publication
Vancouvere29,e30 Canada 2005-2011 345 TF (59)
TA (41)
ES (100) Publication
Skejbye31 Denmark 2006-2010 100 TA (76)
TF (24)
Sa (100) Publication
Créteile32 France 2007-2011 144 TF (100) MC (100) Publication
Parise33 France 2006-2010 125 TF (100) Sa (NA)
18F (NA)
Publication
Rouene34,e35 France 2006-2011 251 TF (75.6)
TA (24.4)
ES (100) Publication
Berlin –Charitee36 Germany 2009-2011 100 TF (100) 18F (83)
Sa (17)
Publication
Berlin -German Hearte37
Germany 2008-2011 500 TA (100) Sa (81.2)
XT (18.8)
Publication
Bonne38 Germany 2008-2012 206 TF (100) 18F (100) Publication
Colognee39 Germany 2008-2011 150 TA (100) Sa (100) Publication
Essene40 Germany 2006-2010 151 TF (100) MC (51)
Sa (49)
Publication
Frankfurte41 Germany 2005-2008 100 TA (100) ES (100) Publication
Gottingene42 Germany 2008-2010 180 TA (54)
TF (46)
18F (13.4)
Sa (86.6)
Publication
Hamburg UHCe43 Germany 2008-2011 326 TF (45.7)
TA (54.3)
18F (13.8)
ES (86.2)
Publication
Heidelberge44 Germany 2008-2011 267 TF (87.6)
TA (12.4)
18F(75.3)
Sa (24.7)
Publication
Bochume45 Germany 2008-2011 198 TF (100) 18F (100) Publication
Leipzige46 Germany 2006-2011 360 TA (100) ES (100) Publication
Lubecke47 Germany 2007-2011 125 TF (100) 18F (100) Publication
Muniche48.e49 Germany 2007-2011 444 TF (67.8)
TA (32.2)
18F(67.7)
Sa(33.3)
Publication
Siegburge50 Germany 2004-2009 576 TF (100) 18F(94.2)
21F (4.1)/25F (1.7)
Conference
Stuttgarte51 Germany 2008-2012 270 TA (100) Sa(80.3)
XT (15.9)
Publication
Jerusaleme52 Israel NA 105 TF (100) 18F (84.8)
XT (15.2)
Publication
Bolognae53 Italy 2008-2010 102 TF (64.7) 18F(64.7)
ES (35.3)
Publication
Milane54,e55 Italy 2007-2010 287 TF (100) 18F (31)
XT (45.9)/ Sa (23.1)
Conference & Publication
Cataniae56 Italy 2005-2011 218 TF (100) MC (89.1)
ES (10.9)
Publication
Padovae57 Italy 2007-2011 191 TF (69.6)
TA (30.4)
MC (45.5)
ES (54.5)
Publication
Leidene58 Netherlands NA 107 TA (55.1)
TF (54.9)
Sa (100) Publication
Rotterdam/ Colombiae59
Netherlands 2005-2011 230 TF (100) 18F (97.9)
21F (2.1)
Publication
Malagae60 Spain 2008-2010 205 TF (100) 18F (100) Publication
Santiago de Spain 2008-2011 85 TF (100) 18F (100) Publication
Compostelae61
Berne62 Switzerland 2007-2011 389 TF (79)
TA (21)
MC (58)
Sa (42)
Publication
London, Kingse63 UK 2007-2009 151 TA (56)
TF (44)
Sa (100) Publication
London, Guyse64 UK 2008-2011 108 TA (84.2) Sa (100) Publication
Supplemental Table 2: Included Single Center studies. TF= Transfemoral , TA= Transapical, MC= Medtronics CoreValve (all/any generation), ES = Edwards valve (all/any generations) 18F =18 F CoreValve, Sa = Edwards Sapien Valve, XT = Edwards Sapient XT. (Supplemental e reference 26-72)
Registry name Age
mean ± SD
Euro score
mean ± SD
STS score
mean ± SD
AV Area
mean ± SD
Prior stroke
(%)
Prior AF
(%)
18F EEe1,e2 81.2 ± 6.4 22.6 ± 13.7 NA 0.64 ± 0.18 7.6 28.3
ADVANCEe3 81 ± 6 19.2 ± 12.4 NA 0.7 13 32.8
ANZ CoreValvee4 83.9 ± 5.9 17.6 ± 11.0 5.9 ± 4.2 0.7 ± 0.2 NA 35.3
ANZ Sourcee5 82.8 28.1 NA 0.62 NA NA
Asia TAVIe6 78.2 ± 7.2 19.7 ± 13.9 NA 0.7 ± 0.2 NA NA
Belgiume7 83 ± 6 28 ± 16 NA 0.61 ± 0.15 15 30
Brazile8 81.5 ± 7.7 20.2 ± 13.8 14.2 ± 11.5 NA 7.4 12.5
Canadae9,e10 81 ± 8 NA 9.8 ± 6.4 0.63 ± 0.17 22.9 34.1
FRANCEe11 82.3 ± 7.3 25.6 ± 11.4 18.9 ± 12.8 0.68 ± 0.16 10.2 NA
FRANCE 2e12 82.7 ± 7.2 21.9 ± 14.3 14.4 ± 12.0 0.67 ± 0.2 9.9 26.6
GARYe13 75.5 ± 7.9 17.5 NA 0.76 ± 0.4 13.5 20
Greecee14 80 ± 8 24.5 ± 13 8.1 ± 6.2 0.66 ± 0.16 NA NA
Ibero-Americane15 81.4 ± 6.3 17.8 ± 13.1 NA 0.62 ± 0.18 11 21.4
I-TA Registrye16 81 ± 6.7 25.6 ± 16.3 10.3 ± 8.4 0.48 ± 0.13 8.5 21.8
Italian CoreValvee17 81 ± 6 23 ± 5 NA NA 7.3 16
PARTNER I Cohort Ae18
83.6 ± 6.8 29.3 ± 16.5 11.8 ± 3.3 0.7 ± 0.2 29.3 40.8
PARTNER I Cohort Be19
83.1 ± 8.6 26.4 ± 17.2 11.6 ± 6.0 0.6 ± 0.2 27.4 32.9
PARTNER IIe20 84.3 ± 8.7 NA 10.6 ± 5.6 0.6 ± 0.2 11.8 38.6
PREVAIL TAe21 81.6 ± 5.8 24.3 ± 7.0 7.5 ± 4.4. 0.7 ± 0.2 22.7 NA
EORP/TCVTe22 81.4 ± 7.1 20.2 ± 13.3 NA 0.68 ± 0.26 12.1 20.1
SOURCEe23 81.2 ± 6.9 25.7 ± 15.2 NA NA 5.9 NA
SOURCE XTe24 81 ± 6.5 20.4 ± 12.4 8.6 ± 7.1 0.7 8.5 25.6
U.K TAVIe25 81.9 ± 7.9 18.5 NA 0.68 NA NA
STS/ACC TVT Registrye26
84(78-88) NA 7(5-11) NA 13 41
CoreValve ExtremeRiske27
83.1 NA NA NA NA NA
Supplemental Table 3: Selected Baseline characteristics of patients in the included Multi center studies. SD = Standard Deviation, AF= Atrial Fibrillation. NA – Not Available.
Registry name Study/Author Age (mean±SD) Euro score (mean±SD)
STS score (mean±SD)
AV area (mean±SD)
Prior stroke (%)
Quebec City Nombela-Francoe28
79±8 24.9±15.2 NA 0.63±0.19 21.8
Vancouver Gurvitche29 82.2±8.1 NA 9.4±5.7 NA 18
Lichtensteine30 79.7±8.2 NA NA NA 26.4
Skejby Moller Nielsene31 80.6±6.7 21.5 (13.5) NA 0.6±0.2 12
Creteil Gallete32 84±7 24±12 NA 0.7±0.2 NA
Paris* Dehedine33 83 (78-87) 24 (16-31) 13 (7-20) 0.39 (0.31-0.46)
62
Rouen Eltchaninoffe34 83.3±6.4 21.9±11.9 NA 0.67±0.56 5.3
Litzlere35 81±6.8 27.5 ± 14.9 NA 0.68 ± 0.16 9.8
Berlin -Charite Stangle36 79±8 19.9±15.4 NA 0.8±0.2 10
Berlin -German Heart*
Pasice37 79.5±8.1 30.4 (21-48.5) 12.2 (6.7-21.6) 0.6 (0.6-0.8) 22.6
Bonn Sedaghate38 80.5±6.5 29.2±17.8 9.5±6.8 0.7±0.2 NA
Cologne Schernere39 79.8 ± 13.1 28.5 ± 19.8 11.7 ± 3.2 NA 13
Essen Bergmanne40 80.2±6.5 21±14 NA NA 10
Frankfurt Dosse41 85±6 36±12 16±3 NA 14
Gottingen Pulse42 82.1±5.4 27±14 NA NA 12
Hamburg UHC* Seifferte43 80.6 (79.8–81.3) 22.7 (21.2–24.2)
8.3 (7.7–8.9) 0.7 (0.7–0.7) 19.3
Heidelberg Bellere44 81.8 ± 5.9 19.64 ± 13.15 7.2 ± 4.01 NA NA
Bochum Gotzmanne45 80±6 22±16 NA 0.7±0.1 NA
Leipzig Haensige46 81.6 ± 6.4 30.0 ± 15.7 11.7 ± 7.8 0.56 ± 0.18 NA
Lubeck Abdel-Wahabe47 81±6.95 24.35±14.61 NA 0.68±0.20 10
Munich Muensterere49 80.2 ± 7.0 19.2 ± 12.8 5.9 ± 4.1 0.687 ± 0.218 11
Bleiziffere48 80.3±6.4 21±13 6.1±3.8 0.67±0.22 35
Siegburg Grubee50 NA NA NA NA NA
Stuttgart Goebele51 81.6±5.7 33.5±18.1 14±13 0.6±0.2 1.5
Jerusalem Perlmane52 80.7±6.6 23.3±15.1 NA 0.65±0.41 NA
Bologna Saiae53 NA NA NA NA NA
Milan Buchanane54 79.45±2.6 21.25±3.94 8.65±2.94 NA 16.3
Mussardoe55 80.1±6.3 26.5±1.6 7.2±5.0 NA 18.2
Catania Tamburinoe56 80.9±5.2 21.1±14.2 8.5±4.3 0.6±0.2 7.4
Padova Thienee57 80.5 ± 6.9 21.43±13.37 NA 0.77 ± 0.20 13.2
Leiden Hooi Ewee58 80.6±7.9 21.3±11.8 8.7±3.6 0.7±0.2 11.5
Rotterdam/ Colombia*
Van Der Boone59 80.2±7.14 16.40 (9.32–23.48)
4.90 (2.94–6.87)
0.66±0.21 6.6
Malaga Munoz-Garciae60 78±2.7 24.3±3.08 8.75±2.37 1.6±0.6 8.2
Santiago de Compostela*
Lopez-Oteroe61 83±5.43 17.7 (11.3-23.4) NA NA NA
Bern Wenawesere62 82.5+5.8 24.3+14.2 6.8+5.3 0.6±0.2 8
London, Kings Dworakowskie63 82.5±7.4 21.6±11.9 NA 0.62±0.16 18.5
London, Guys Bapate64 82.64±7.3 23.5±13.2 NA NA 16.5
Supplemental Table 4: Selected Baseline characteristics of patients in the included Single center studies. SD = Standard Deviation, AF= Atrial Fibrillation, NA – Not Available. *- Data presented as median and Inter Quartile Range.
Registry Name VARCStroke
AdjudicationMajor Stroke
Minor Stroke
TIA24 -48 hrs
StrokeIn Hospital
Stroke30 day Stroke
18FEEe1,e2 No NA No No Yes Yes No Yes
ADVANCEe3 Yes Neurologist Yes Yes No No No Yes
ANZ CoreValvee4 YesIndependent
CECNo No No No No Yes
ANZ Sourcee5 YesIndependent
CECNo No No No No Yes
Asia TAVIe6 No NA No No Yes No No Yes
Belgiume7 No NA No No Yes No No Yes
Brazile8 YesIndependent
CECNo No No No No Yes
Canadae9,e10 No NA No No No Yes No Yes
FRANCEe11 No NA No No No No No Yes
FRANCE 2e12 YesIndependent
CECYes Yes No No No Yes
GARYe13 No NA No No No No Yes No
Greecee14 Yes NA No No No No No Yes
Ibero-Americane15 Yes NA Yes Yes Yes No Yes Yes
I-TAe16 Yes NA Yes Yes Yes No No Yes
Italian CoreValvee17 Yes
Independent CEC
Yes No No Yes No Yes
PARTNER I Cohort Ae18 No
Independent CEC
Yes Yes Yes Yes No Yes
PARTNER I Cohort Be19 No
Independent CEC
Yes Yes Yes No No Yes
PARTNER IIe20 Yes Neurologist Yes Yes Yes No No Yes
PREVAIL TAe21 No Committee No No No No No Yes
EORP/TCVTe22 Yes NA No No No No Yes Yes
SOURCEe23 NoPrincipal
InvestigatorNo No No No No Yes
SOURCE XTe24 YesIndependent
CECNo No Yes No No Yes
U.K TAVIe25 No NA No No Yes No Yes No
STS/ACC TVT Registrye26 Yes Cardiologist No No No Yes Yes Yes
CoreValve Extreme Riske27 Yes NA NA NA NA NA NA NA
Supplemental Table 5: Reporting of stroke by multicenter studies. VARC= Valve Academic Research Consortium, CEC= Clinical Events Committee.
Single Center Author VARC Stroke Major Minor TIA 24 -48 hrs In Hospital 30 day
Adjudication Stroke Stroke Stroke Stroke Stroke
Quebec City Nombela-Francoe28
Yes NA Yes Yes Yes Yes No Yes
Vancouver Gurvitche29 Yes Neurologist Yes Yes Yes No No Yes
Litchensteine30 No NA No No No No No Yes
Skejby Nielsene31 No NA Yes No No Yes No No
Creteil Gallete32 Yes NA No No No No No Yes
Paris Dehedine33 Yes NA No No No No Yes No
Rouen Eltchaninoffe34 Yes NA Yes Yes Yes No No Yes
Litzlere35 No NA No No No Yes Yes No
Berlin-Charite Stangle36 Yes NA Yes Yes Yes Yes No Yes
Berlin-German Heart Pasice37 Yes NA Yes Yes No No No Yes
Bonn Sedaghate38 Yes NA No No No Yes Yes No
Cologne Schernere39 Yes NA Yes Yes Yes Yes Yes No
Essen Bergmanne40 No NA No No No Yes No No
Frankfurt Dosse41 No NA No No No Yes Yes Yes
Gottingen Pulse42 Yes NA No No Yes Yes Yes Yes
Hamburg UHC Seifferte43 Yes NA Yes Yes Yes Yes Yes Yes
Heidelberg Bellere44 Yes NA Yes No No No No Yes
Bochum Gotzmanne45 Yes NA No No No Yes No Yes
Leipzig Haensige46 Yes NA Yes Yes Yes Yes Yes No
Lubeck Abdel-Wahabe47 Yes NA Yes No No No No Yes
Munich Bleiziffere48 No NA No No Yes Yes No Yes
Muensterere49 Yes NA No No Yes Yes Yes No
Siegburg Gruebee50 No NA No No No No No Yes
Stuttgart Goebele51 Yes NA No No Yes No No Yes
Jerusalem Perlmane52 Yes NA No No Yes Yes Yes Yes
Bologna Saiae53 Yes NA No No No No No Yes
Milan Buchanane54 Yes NA No No No No No Yes
Mussardoe55 Yes NA Yes No Yes Yes Yes Yes
Catania Tamburinoe56 Yes NA No No No No No Yes
Padova Fraccaroe57 Yes NA No No No Yes Yes No
Leiden Ewee58 No NA No No No Yes Yes No
Rotterdam/Colombia Van der Boone59 Yes Neurologist Yes Yes Yes Yes Yes No
Malaga Munoz Garciae60 Yes NA No No No No No Yes
Santiago de Compostela
Lopez-Oteroe61 Yes NA Yes No Yes Yes No No
Bern Wenawesere62 Yes NA Yes Yes Yes No No Yes
London, Kings Dwarakowskie63 No NA No No No No No Yes
London, Guys Bapate64 No NA No No No No No Yes
Supplemental Table 6: Reporting of stroke by multicenter studies. VARC= Valve Academic Research Consortium, CEC= Clinical Events Committee.
Study Location Period Valve Approach
24Fe65 Germany 2005-2005 MC TF
21Fe66 Germany/Canada 2005-2006 MC TF
Walthere67 Germany 2006-2006 CE TA
Walthere68 Germany/USA 2006-2006 Sa TA
REVIVALe69 USA 2005-2006 CE TF
REVIVE2e70 Europe 2006-2007 Sa TF
REVIVAL2e71 USA 2006-2008 Sa TA
Walthere72 Germany 2006-2007 Sa TA
Vancouver Canada 2005-2008 CE/Sa TF/TA
Expe73
18Fe74 Europe 2006-2008 MC TF
PARTNER EUe75 Europe 2007-2008 Sa TF/TA
TRAVERCEe76 Europe 2006-2008 CE/Sa TA
Supplemental Table 7: Included Feasibility Studies. F = French scale, MC= Medtronics CoreValve, CE= Cribier Edwards, Sa= Edwards Sapien, TF= Transfemoral and TA= Transapical.
Center Approach
Early Late
Munich TF Bleiziffere77 Muensterere49
Vancouver
TF Gurvitche78 Gurvitche78
Bern TF Storteckye79 Wenawesere62
Paris TF Himberte80 Dehedine33
Rouen TF Eltachninoffe34
Eltchaninoffe34
Catania TF Paolo Ussiae81
Tamburinoe56
Siegburg
TF Grubee82 Grubee50
Milan TF Godinoe83 Musssardoe55/Buchanane54
Rotterdam
TF Nuis RJe84 Van Der Boone59
Berlin TA Pasice85 Pasice35
Cologne TA Schernere39 Schernere39
Leipzig TA Kempferte86 Haensige46
Munich TA Bleiziffere77 Bleiziffere48
Vancouver
TA Higginse87 Higginse87
Supplemental Table 8: High volume centers with corresponding early and late publication. TF= Transfemoral and TA = Transapical.
Study Name Surgical Risk group
Higginse88 High Risk
Wilbringe89 High Risk
Stohre90 High Risk
Holzheye91 High Risk
Conradie92 High Risk
PARTNER Ie18 High Risk
Staccatoe93 Intermediate Risk
Latibe94 Intermediate Risk
Osnabruggee95 Intermediate Risk
Supplemental Table 9: Studies comparing Transcatheter Aortic Valve Replacement (TAVR) vs. Surgical aortic valve replacement (SAVR) – TAVR vs. SAVR.
Patient Specific Risk factors for Stroke:
Risk Factor Stroke Association
Agee96-98 Increased age was significantly related to a higher number of new infarcts (r =0.37, pFairbairn et al.
BMIe96,e99 BMI ≤20 kg/m2 was a predictor of stroke and death. (HR 4.11, 95% CI 1.33-12.70)-Pilgrim et al.
History of Stroke e96-e100 Prior history of stroke is more frequent in patients that have a stroke after TAVR (21% vs. 7%)-Stortecky et al.
Also associated with stroke beyond the first 30 days (HR 2.35, 95% CI 1.17-4.73)- Franco et al.
New onset Atrial Fibrillatione100-103 Is an important predictor of early (HR 2.96, 95% CI 1.21-7.25) and late stroke after TAVR (HR
1.93, 95% CI 1.15- 3.24) – Franco et al.
May be increased with TA approach- Santos et al.
Procedure Specific Predictors of Stroke
Procedural Step Theories for stroke Supportive Evidence
Pre implantation Instrumentation – Vessel puncture to Valvuloplastye97,e98,e104-
e107
Thrombo embolism from catheters, Air embolization from repeated flushing and multiple exchanges of wires and catheters.
1. Prolonged procedural time increases the risk of stroke.
2. Total HITS load comparable to valve deployment.
Rapid Ventricular Pacing (Testing /BAV)e108-e110
Temporary tachycardic cardiac arrest – cerebral hypoperfusion
1. Hyper intense signals on DW MRI without neurological or neurocognitive impairment.
Balloon Valvuloplasty of the Aortic Valvee109,e111
Disruption of endothelial layer and subsequent embolization of calcific material from the aortic valve.
1. The risk of stroke varies from 1-2%.
2. Second to valve deployment in load of HITS per unit time of procedure in transcranial Doppler studies during TAVR.
3. Smaller Aortic Valve Area increases the risk of stroke.
Trafficking of the delivery catheter with mounted prosthetic valve across the aortic arche97,e109.
Large caliber less flexible delivery catheters are more traumatic and prone to dislodge atheromatous debris.
1. Atheromatous plaques > 5 mm in thickness or mobile atheroma in the arch and descending thoracic aorta increase the risk of stroke during aortic trafficking.
2. Declining risk of stroke with new generation delivery systems (current analysis).
Valve positioning and Implantatione104,e107,e111,e112
Embolization of calcific and atheromatous debris from valve manipulation and crushing.
1. Small valve areas and higher transvalvular gradients increase stroke risk (higher valve calcification).
2. Peak HITS load is observed during implantation.
3. Repeated attempts associated with increased risk of stroke (2.8% vs. 12%).
Valve Dislodgement/Embolizatione100 Mechanical friction between prosthesis frame and aortic wall.
1. More common with self expanding CoreValve.
Balloon Post Dilation (BPD)e100,e113 Additional dislodgement and embolization of calcific debris from the native aortic
Smaller valve area and higher degree of calcification are associated with an increased risk of BPD and hence stroke.
valve.
Supplemental Table 10: Risk factors for Stroke after Transcatheter Aortic Valve Replacement. BMI = Body Mass Index, COPD = Chronic Obstructive Pulmonary Disease, HITS= High Intensity Transcranial Doppler Signals, BAV = Balloon Aortic Valvuloplasty. r= regression coefficient, HR= Hazards Ratio, CI= Confidence Intervals.