Severe Aortic Wall Thrombus Predicts Higher Risks in transfemoral TAVR: Study reveals

Thromboembolic events, notably strokes, continue to pose significant challenges in transcatheter aortic valve replacement (TAVR), according to researchers. Despite efforts, embolic protection devices have not demonstrated substantial clinical benefits in extensive randomized clinical trials. Aortic wall thrombus is frequently detected on multidetector CT during TAVR evaluations, yet its prognostic implications remain uncertain. Considering this, Marc Bonnet, Cardiology Department, Hospital Annecy-Genevois, Metz-Tessy, France, and colleagues sought to evaluate the association between the AWT presence and the incidence of thromboembolic outcomes in patients undergoing TF TAVR for severe aortic stenosis.

For this purpose, the researchers conducted a prospective cohort study of consecutive patients who underwent TF TAVR for severe aortic stenosis between 2011 and 2022. A specific scale ranging from 0 to 10 was employed for qualitative assessment of aortic wall thrombus (AWT).

The primary outcome measured a composite of procedural thromboembolic events, including ischemic stroke, blue toe syndrome, bowel ischemia, or infarction of other solid organs. Secondary endpoints included ischemic strokes and procedural mortality.

The following were the key findings of the study:

• Of the 641 patients included, severe AWT (score ≥8) was identified in 11.4%.
• Severe AWT presence was strongly associated with an increase in the primary outcome (OR: 8.48).
• This relationship persisted following multivariable analysis, which adjusted for comorbidities and procedural characteristics.
• The presence of severe AWT was also associated with an increased incidence of stroke and procedural death (OR: 5.66 and OR: 4.66, respectively).

In their editorial accompanying the study, Yousif Ahmad, MD, PhD, and Alexandra J. Lansky, MD, from Yale School of Medicine in New Haven, CT, highlight that the Sentinel device (Boston Scientific) evaluated in PROTECTED TAVR is not the only option. They note that other cerebral embolic protection tools currently in development may offer improved efficacy.

The editorial introduces a new perspective, suggesting that rather than solely emphasizing new devices or technical aspects, an alternative global approach to reducing stroke and other embolic complications after TAVR could involve identifying high-risk patients who would derive the greatest benefit from protective measures.

Reference:

Bonnet M, Maxo L, Lohse T, et al. Association between aortic wall thrombus and thromboembolic events after transfemoral transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2024;17:1680-1690.