title: Incidence and predictors of debris embolizing to the brain during transcatheter aortic valve implantation.
abstract: OBJECTIVE
  The aim of this study was to identify variables associated with tissue fragment embolization during transcatheter aortic valve replacement (TAVR).
  
  
  BACKGROUND
  Brain magnetic resonance imaging and transcranial Doppler studies have revealed that cerebrovascular embolization occurs frequently during TAVR. Embolized material may be r thrombotic, tissue derived, or catheter (foreign material) fragments.
  
  
  METHODS
  A total of 81 patients underwent TAVR with a dual filter-based embolic protection device (Montage Dual Filter System, Claret Medical, Inc., Santa Rosa, California) deployed in the brachiocephalic trunk and left common carotid artery. Both balloon-expandable and self-expanding transcatheter heart valves (THVs) were used. Filters were retrieved after TAVR and sent for histopathological analysis.
  
  
  RESULTS
  Overall, debris was captured in 86% of patients. Captured material varied in size from 0.1 to 9.0 mm. Thrombotic material was found in 74% of patients and tissue-derived debris in 63%. Tissue fragments were found more often with balloon-expandable THVs (79% vs. 56%; p = 0.05). The embolized tissue originated from the native aortic valve leaflets, aortic wall, or left ventricular myocardium. On multivariable logistic regression analysis, balloon-expandable THVs (odds ratio: 7.315; 95% confidence interval: 1.398 to 38.289; p = 0.018) and cover index (odds ratio: 1.141; 95% confidence interval: 1.014 to 1.283; p = 0.028) were independent predictors of tissue embolization.
  
  
  CONCLUSIONS
  Debris is captured with filter-based embolic protection in the vast majority of patients undergoing TAVR. Tissue-derived material is found in 63% of cases and is more frequent with the use of balloon-expandable systems and more oversizing.
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands. Electronic address: n.vanmieghem@erasmusmc.nl.
authors.forename: Nicolas M
authors.initials: NM
authors.lastname: Van Mieghem
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Nahid
authors.initials: N
authors.lastname: El Faquir
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Zouhair
authors.initials: Z
authors.lastname: Rahhab
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Ramón
authors.initials: R
authors.lastname: Rodríguez-Olivares
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Wilschut
authors.affiliation: Department of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Ouhlous
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Tjebbe W
authors.initials: TW
authors.lastname: Galema
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Marcel L
authors.initials: ML
authors.lastname: Geleijnse
authors.affiliation: Department of Cardio-Thoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Arie-Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.affiliation: Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Marguerite E I
authors.initials: ME
authors.lastname: Schipper
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Peter P
authors.initials: PP
authors.lastname: de Jaegere
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve; D063126:Balloon Valvuloplasty / Q000009:adverse effects; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D016009:Chi-Square Distribution; D057505:Embolic Protection Devices; D005260:Female; D005548:Foreign-Body Migration / Q000175:diagnosis / Q000453:epidemiology*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D015994:Incidence; D020766:Intracranial Embolism / Q000175:diagnosis / Q000453:epidemiology*; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D015999:Multivariate Analysis; D009426:Netherlands / Q000453:epidemiology; D016017:Odds Ratio; D011474:Prosthesis Design; D012307:Risk Factors; D013927:Thrombosis / Q000175:diagnosis / Q000453:epidemiology*; D017585:Ultrasonography, Doppler, Transcranial
keywords: TAVR; aortic stenosis; embolization