Impact of asymptomatic carotid stenosis on mid term outcome of transcatheter aortic valve replacement

Introduction Stroke is a potential major complication of aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI), and balloon aortic valvuloplasty (BAV). Although its occurrence is rare, stroke significantly affects survival and quality of life. Peripheral vascular disease and carotid artery disease are independent risk factors that have been identified as predictors of operative death according to surgical risk scores. The presence of a significant carotid stenosis may increase the surgical risk leading to the choice of a percutaneous transaortic valve implantation rather than a surgical AVR. At present there is no evidence that describes the impact of asymptomatic significant carotid stenosis detected accidentally during preoperative evaluation on the onset of cerebrovascular periprocedural events after TAVI. Population In this first analysis we considered 521 patients with severe aortic stenosis (AS) and cardiac symptoms (New York Heart Association [NYHA] class II function or worse). A score of at least 20 % on the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and 10% on the risk model developed by the Society for Thoracic Surgeons (STS)., Follow-up All patients underwent clinical surveillance, bio-chemical tests, electrocardiogram and echocardiogram before hospital discharge. The follow-up assessment included medical examination, electrocardiogram and echocardiogram to perform valve imaging and hemodynamic evaluation. It was performed at our Center or at the treating cardiologist ambulatory 30 days and one year after the procedure. The events considered were mortality (by all-cause and cardiovascular death), myocardial infarction, stroke and transient ischemic attack (TIA), bleeding (minor and life-threatening bleeding), acute renal failure, vascular complications, disturb of conduction and arrhythmias and the combined criteria of safety, according to VARC and VARC 2 definitions. Procedure The coexistence of carotid and peripheral artery diseases not only further increases risk and long-term mortality but influences also technical approaches since all centers adopt a policy of using the transfemoral approach first, with criteria for the use of non-transfemoral approaches that are based on the size and degree of tortuosity, calcifications, and atheroma of the aorto-iliofemoral arterial tree, as assessed by the multidisciplinary team. In our Center, preventive measures have been taken to limit the risk associated to the procedure in our patients presenting carotid artery stenosis. Results The main findings of the current study are the following: (a) no correlation has been observed about the presence of an asymptomatic carotid artery stenosis discovered before the TAVI procedure and mortality, rate of cerebrovascular events (stroke or TIA) and myocardial infarction during the first postoperative month; (b) no differences concerning all-causes and cardiovascular mortality and onset of cerebrovascular events (stroke/TIA) at long-term have been shown between patients with and without CAS. Conclusion The presence of asymptomatic carotid stenosis is not a risk factor for cerebrovascular events after percutaneous aortic valve implantation at 30 days and one-year follow-up. Cerebrovascular events after TAVI occur in a vulnerability period extending to 1 month post-procedure. No difference exists in the CVE rate with regard to the type of valve or the access route. Coronary, carotid, aortic, iliac and femoral artery disease are often found in elderly patients presenting with severe symptomatic AS undergoing TAVI. These patients are also affected by several clinical factors and frailty that correlate with the presence and severity of arterial pathologies and can impact on incidence of CVEs and longterm survival