Author + information
- Received April 5, 2013
- Accepted April 11, 2013
- Published online September 1, 2013.
- Pablo Salinas, MD∗∗ (, )
- Raul Moreno, MD, PhD∗,
- Remedios Frutos, MD† and
- Jose Luis Lopez-Sendon, MD, PhD∗
- ∗Department of Cardiology, Interventional Cardiology, University Hospital La Paz, Madrid, Spain
- †Department of Radiology, Neuroradiology, University Hospital La Paz, Madrid, Spain
- ↵∗Reprint requests and correspondence:
Dr. Pablo Salinas, Interventional Cardiology, Department of Cardiology, University Hospital La Paz, Madrid, Castellana 267, 28046 Madrid, Spain.
- embolic stroke
- interventional cardiology
- interventional radiology
- transcatheter aortic valve implantation
An 88-year-old woman with critical aortic stenosis was scheduled for transfemoral transcatheter aortic valve implantation (TAVI). She received pre-procedural aspirin plus clopidogrel, and 100 IU/kg of unfractionated heparin during the procedure. The procedure was uneventful, and the balloon-expandable valve was successfully deployed. After deflating the balloon, an echo-dense mobile mass was seen in the left ventricular outflow tract (Fig. 1, Online Video 1), probably attached to the intraventricular portion of the guidewire. This mass was not present after valvuloplasty, so torn leaflets from the native valve were unlikely. Activated clotting time was 270 s. When the balloon catheter and guidewire were withdrawn, the mass disappeared.
The patient remained stable with nice prosthesis gradients. All pulses were palpable, but after prompt reversal of anesthesia, a complete left hemiparesis was found. A brain computed tomography scan confirmed a large right middle cerebral artery (RMCA) stroke. Immediate mechanical neurovascular rescue was attempted. In the initial angiography, there was a complete occlusion of the M1 branch of the RMCA with thrombus in the A1 branch (Fig. 2). Mechanical thrombectomy was performed with a Solitaire AB device (ev3, Endovascular Inc., Plymouth, Minnesota), extracting a 13-mm thrombus (Fig. 3). The control angiogram shows complete RMCA reperfusion (Fig. 4). The neurological deficit improved to modified Rankin scale 1 at discharge and remained unchanged after 6 months of follow-up.
Strokes during TAVI are attributed to calcific debris embolization, native valve guidewire crossing, and aortic balloon valvuloplasty (1). Catheter-related thrombus is a known cause of stroke during percutaneous coronary intervention with an incidence of approximately 0.4% (2). However, catheter-related thrombus during a TAVI procedure has not been previously reported and merits a few forethoughts. First, the optimal level of anticoagulation remains uncertain. Second, it is important to promptly reverse anesthesia/sedation to assess any potential neurological deficit. Finally, interventional treatment for embolic strokes should be considered in selected cases.
For the accompanying video, please see the online version of this paper.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 5, 2013.
- Accepted April 11, 2013.
- American College of Cardiology Foundation