Stroke After Aortic Valve Replacement
The Known and Unknown
Stroke after aortic valve surgery is known as a devastating complication and is associated with increased morbidity and mortality.1 Transcatheter aortic valve replacement (TAVR) has emerged as a valid alternative for surgical aortic valve replacement (SAVR) both in inoperable patients and in those at high risk for surgery; however, the encouraging results were hampered by various complications, including stroke. In the pivotal Placement of Aortic Transcatheter (PARTNER) trial, the initial stroke rates of TAVR patients were almost double the stroke rates in patients who underwent SAVR (3.8% versus 2.1%; P=0.2),2 and this potentially affected the decision to choose 1 procedure over the other. However, continued follow-up to 3 years equated the stroke rates in SAVR and TAVR. More recent SAVR and TAVR data indicate that stroke rates in both procedural alternatives has declined, with rates of 1.7% to 2.5% from large registries such as the Society for Thoracic Surgeons and the German Aortic Valve registries.3,4 However, the unknowns with respect to stroke after AVR are numerous. In evaluations of neurological complications, overt clinical and obvious disabling stroke is only 1 potential neurological event that could occur after the procedure, and as opposed to permanent neurological deficits, these events either are clinically silent or go unnoticed because physicians are not performing tests to rule out these events (ie, cognitive deficits). The incidence and impact of these events on outcome are unknown. Furthermore, the role and impact of magnetic resonance imaging (MRI) detection of silent strokes also remain unknown.
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In the current issue of Circulation, Messé and colleagues5 prospectively assessed the incidence of both clinical stroke and silent neurological events in 196 patients ≥65 years of age who underwent SAVR as recorded by serial neurological examinations and MRI. The incidence …