title: Silent cerebral injury after transcatheter aortic valve implantation and the preventive role of embolic protection devices: A systematic review and meta-analysis.
abstract: BACKGROUND
  The aims of this study were: 1) to evaluate silent cerebral injury detected by cerebral diffusion weighted magnetic resonance imaging (DW-MRI) after transcatheter aortic valve implantation (TAVI); and 2) to assess the efficacy of embolic protection devices (EPDs) on DW-MRI endpoints.
  
  
  METHODS
  We included in a pooled analysis 25 prospective studies reporting post-procedural cerebral DW-MRI data after TAVI (n=1225). Among these studies, we included in a meta-analysis 6 studies investigating TAVI performed with versus without EPDs (n=384). Primary endpoints were the number of new lesions per patient and the total lesion volume, while secondary endpoints were the number of patients with new lesions and the single lesion volume.
  
  
  RESULTS
  The main pooled DW-MRI outcomes were: patients with new ischemic lesions, 77.5% (95% confidence interval=71.7-83.3%); total lesion volume, 437.5mm(3) (286.7-588.3mm(3)); single lesion volume, 78.1mm(3) (56.7-99.5mm(3)); and number of new lesions per patient, 4.2 (3.4-5.0). The use of EPDs was associated with a significant reduction in total lesion volume (mean difference [95% confidence interval]=-111.1mm(3) [-203.6 to -18.6mm(3)]; p=0.02) and single lesion volume (-12.1mm(3) [-18.3 to -6.0mm(3)]; p=0.0001) after TAVI.
  
  
  CONCLUSIONS
  Silent cerebral injury occurs in the majority of patients undergoing TAVI and DW-MRI allows a precise characterization of new ischemic brain lesions. EPDs reduce the total and single volume of such lesions detected after the procedure, although the number of new lesions per patient and the number of patients with new lesions are not significantly reduced by such devices.
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Pagnesi
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Enrico A
authors.initials: EA
authors.lastname: Martino
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Chiarito
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Mangieri
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy; Imperial College, London, United Kingdom.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Jabbour
authors.affiliation: Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Nicolas M
authors.initials: NM
authors.lastname: Van Mieghem
authors.affiliation: Department of Medicine, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, United States.
authors.forename: Susheel K
authors.initials: SK
authors.lastname: Kodali
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Cosmo
authors.initials: C
authors.lastname: Godino
authors.affiliation: Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Landoni
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy. Electronic address: alatib@gmail.com.
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
mesh_terms: D001024:Aortic Valve Stenosis / Q000601:surgery*; D058070:Asymptomatic Diseases; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods; D057505:Embolic Protection Devices / Q000706:statistics & numerical data*; D006801:Humans; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control*; D020521:Stroke / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects* / Q000379:methods; D016896:Treatment Outcome
keywords: Brain injury; Cerebral ischemia; Cerebral protection device; Magnetic resonance imaging; Meta-analysis; TAVI