Incidence and predictors of debris embolizing to the brain during transcatheter aortic valve implantation

JACC Cardiovasc Interv. 2015 Apr 27;8(5):718-24. doi: 10.1016/j.jcin.2015.01.020.


Objectives: 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.

Keywords: TAVR; aortic stenosis; embolization.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve*
  • Balloon Valvuloplasty / adverse effects
  • Cardiac Catheterization / adverse effects*
  • Cardiac Catheterization / instrumentation
  • Cardiac Catheterization / methods
  • Chi-Square Distribution
  • Embolic Protection Devices
  • Female
  • Foreign-Body Migration / diagnosis
  • Foreign-Body Migration / epidemiology*
  • Heart Valve Prosthesis
  • Heart Valve Prosthesis Implantation / adverse effects*
  • Heart Valve Prosthesis Implantation / instrumentation
  • Heart Valve Prosthesis Implantation / methods
  • Humans
  • Incidence
  • Intracranial Embolism / diagnosis
  • Intracranial Embolism / epidemiology*
  • Logistic Models
  • Magnetic Resonance Imaging
  • Male
  • Multivariate Analysis
  • Netherlands / epidemiology
  • Odds Ratio
  • Prosthesis Design
  • Risk Factors
  • Thrombosis / diagnosis
  • Thrombosis / epidemiology*
  • Ultrasonography, Doppler, Transcranial