Tailor-Made Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement in an Extremely High-Risk Patient

An 80-year-old man with very severe aortic stenosis (aortic valve peak velocity=5.23 m/s; aortic valve area=0.57 cm²) was referred for transcatheter aortic valve implantation (TAVI) due to syncope. Coronary angiography showed no significant stenosis, but induced symptomatic cerebral infarction, manifesting as hemiplegia. Magnetic resonance imaging (MRI) showed acute multiple cerebral infarcts, suggesting cardioembolic infarction through the contact of a catheter with a heavily calcified aortic valve or arterial wall (Figure A,B). Considering the recent cerebral infarction, we postponed TAVI, and applied tailor-made cerebral embolic protection during TAVI because of the high risk for periprocedural stroke.

Figure.

(A) Diffusion-weighted magnetic resonance imaging (DW-MRI) after coronary angiography showing acute multiple cerebral infarcts. (B) Computed tomography showing a heavily calcified aortic valve. (C) Cerebral embolic protection devices (arrow). (D) Final angiography after transcatheter aortic valve implantation (TAVI). (E) Extracted cerebral protection devices, containing yellow material and thrombus. (F) Captured tissue fragment representing arterial wall containing elastin and collagen fibers with cholesterol crystal (arrow) (Hematoxylin-Eosin stain and Elastica Masson stain). (G) Platelet-rich thrombus (Hematoxylin-Eosin stain). (H) Thrombus and collagen fibers (Elastica Masson stain). (I) Postoperative DW-MRI showing new ischemic lesions in the right thalamus and the left cerebellum.

Spider FX [Medtronic, Minneapolis, MN, USA] were deployed in the right vertebral artery (Spider FX 4 mm), the left carotid internal artery (Spider FX 6 mm), and the right internal carotid artery (Spider FX 6 mm) (Figure C). The filter size was selected according to the vessel diameter, and no filter was placed in the hypoplastic left vertebral artery. Then, we performed retrograde balloon aortic valvuloplasty with a 22-mm INOUE balloon (Toray, Tokyo, Japan), and performed a transfemoral implantation of a 29-mm Evolut PRO+ (Medtronic, Minneapolis, MN, USA) (Figure D). All filters were retrieved after TAVI. Exploration of the filters showed macroscopic evidence of captured embolic debris related to the vascular bed (valve tissue, arterial wall, and collagen) and the platelet-rich thrombus (Figure E–H). It was estimated that a tragic cerebral embolism was unavoidable if such a large amount of debris was scattered into the cerebral arteries. Postoperative diffusion-weighted MRI showed new, small ischemic lesions in the perfusion of area of the vertebrobasilar artery, covered by the left vertebral artery (Figure I), but neurological examinations revealed no clinical stroke, showing the same neurological performance as that observed preoperatively.

Disclosures

The authors declare no conflicts of interest.