title: Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study.
abstract: BACKGROUND
  The risk of stroke after transfemoral aortic valve implantation (TAVI) due to dislodgement and subsequent embolization of debris from aortic arch atheroma or from the calcified valve itself ranges between 2% and 10%. The rate of clinically silent cerebral ischemia is unknown but may be even higher.
  
  
  RESULTS
  Thirty-two patients who underwent TAVI with the use of a balloon-expandable (n=22) or self-expandable (n=10) stent valve prosthesis were included in this descriptive study and compared with a historical control group of 21 patients undergoing open surgical aortic valve replacement. Periprocedural apparent and silent cerebral ischemia was assessed by neurological testing and serial cerebral diffusion-weighted magnetic resonance imaging at baseline, at 3.4 (2.5 to 4.4) days after the procedure, and at 3 months. TAVI was successful in all patients. After the procedure, new foci of restricted diffusion on cerebral diffusion-weighted magnetic resonance imaging were found in 27 of 32 TAVI patients (84%) and were more frequent than after open surgery (10 of 21 patients [48%]; P=0.011). These lesions were usually multiple (1 to 19 per patient) and dispersed in both hemispheres in a pattern suggesting cerebral embolization. Volumes of these lesions were significantly smaller after TAVI than after surgery (77 [59 to 94] versus 224 [111 to 338] mm(3); P<0.001). There were neither measurable impairments of neurocognitive function nor apparent neurological events during the in-hospital period among TAVI patients, but there was 1 stroke (5%) in the surgical patient group. On 3-month follow-up diffusion-weighted magnetic resonance imaging, there were no new foci of restricted diffusion, and there was no residual signal change associated with the majority (80%) of the foci detected in the periprocedural period.
  
  
  CONCLUSIONS
  Clinically silent new foci of restricted diffusion on cerebral magnetic resonance imaging were detected in almost all patients (84%) undergoing TAVI. Although typically multiple, these foci were not associated with apparent neurological events or measurable deterioration of neurocognitive function during 3-month follow-up. Further work needs to be directed to determine the clinical significance of these findings in a larger patient population.
authors.affiliation: West German Heart Center Essen, Department of Cardiology, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany. Philipp.Kahlert@uk-essen.de
authors.forename: Philipp
authors.initials: P
authors.lastname: Kahlert
authors.forename: Stephan C
authors.initials: SC
authors.lastname: Knipp
authors.forename: Marc
authors.initials: M
authors.lastname: Schlamann
authors.forename: Matthias
authors.initials: M
authors.lastname: Thielmann
authors.forename: Fadi
authors.initials: F
authors.lastname: Al-Rashid
authors.forename: Marcel
authors.initials: M
authors.lastname: Weber
authors.forename: Uwe
authors.initials: U
authors.lastname: Johansson
authors.forename: Daniel
authors.initials: D
authors.lastname: Wendt
authors.forename: Heinz G
authors.initials: HG
authors.lastname: Jakob
authors.forename: Michael
authors.initials: M
authors.lastname: Forsting
authors.forename: Stefan
authors.initials: S
authors.lastname: Sack
authors.forename: Raimund
authors.initials: R
authors.lastname: Erbel
authors.forename: Holger
authors.initials: H
authors.lastname: Eggebrecht
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis* / Q000209:etiology*; D004058:Diffusion; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome