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Stroke and Cardiovascular Outcomes in Patients With Carotid Disease Undergoing Transcatheter Aortic Valve Replacement
Ajar Kochar1, Zhuokai Li2, J Kevin Harrison2
1From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.) ajar.kochar@duke.edu.
Insights
Carotid artery disease (CD) is common in transcatheter aortic valve replacement (TAVR) patients but does not increase stroke or mortality risk. Further research is needed to understand post-TAVR stroke causes beyond CD.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Interventional Cardiology
Background:
- Stroke is a significant complication for patients undergoing transcatheter aortic valve replacement (TAVR).
- The impact of co-existing carotid artery disease (CD) on TAVR outcomes, specifically stroke and mortality, remains unclear.
- Carotid artery disease affects approximately 22% of patients undergoing TAVR.
Purpose of the Study:
- To investigate the association between carotid artery disease (CD) and the risk of stroke and all-cause mortality following transcatheter aortic valve replacement (TAVR).
- To compare stroke and mortality rates at 30 days and 1 year between TAVR patients with and without CD.
- To evaluate if the severity of CD influences stroke and mortality risk after TAVR.
Main Methods:
- Utilized data from the STS/ACC Transcatheter Valve Therapies Registry (2013-2015) linked with Medicare claims.
- Included 29,143 patients who underwent TAVR across 390 US sites.
- Employed proportional hazards models to compare outcomes between patients with no CD and varying degrees of CD (moderate, severe, occlusive), adjusting for baseline covariates.
Main Results:
- No significant association was found between the presence of CD and 30-day stroke (aHR 1.16) or mortality (aHR 1.10).
- Similarly, no association was observed between CD and 1-year stroke (aHR 1.03) or mortality (aHR 1.02).
- The severity of CD did not significantly alter the risk-adjusted outcomes for stroke or mortality at either time point.
Conclusions:
- Carotid artery disease is prevalent in TAVR patients but does not appear to increase the risk of stroke or mortality within one year post-procedure.
- The findings suggest that stroke after TAVR may stem from mechanisms unrelated to carotid artery disease.
- Further investigation into alternative stroke etiologies in the TAVR population is warranted.
Background:
Stroke is a serious complication of both transcatheter aortic valve replacement (TAVR) and carotid artery disease (CD). The implications of CD in patients undergoing TAVR are unclear.
Methods And Results:
The Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapies Registry, consisting of data from consecutive US TAVR cases during the years 2013 to 2015, was linked to Medicare claims data to ascertain 30-day and 1-year cumulative incidence rates of stroke and all-cause mortality. We compared 30-day and 1-year stroke and mortality outcomes between patients with no-CD and patients with moderate, severe, and occlusive CD and adjusted for baseline covariates using proportional hazards models. Among 29 143 patients undergoing TAVR across 390 US sites, 22% had CD. Patients with CD had higher rates of prior hypertension, diabetes mellitus, stroke, and myocardial infarction. Observed in-hospital stroke rates were 2.0% among no-CD, 2.5% among moderate CD, 3.0% among severe CD, and 2.6% among occlusive CD. There was no association between the presence of CD and 30-day stroke (adjusted hazard ratio, 1.16; 95% confidence interval, 0.94-1.43) or mortality (adjusted hazard ratio, 1.10; 95% confidence interval, 0.95-1.28). There was no association between CD and 1-year stroke (adjusted hazard ratio, 1.03; 95% confidence interval, 0.86-1.24) or mortality (adjusted hazard ratio, 1.02; 95% confidence interval, 0.93-1.12). Furthermore, there was no significant risk-adjusted association between severity of CD and 30-day or 1-year stroke or mortality.
Conclusions:
CD is common among TAVR patients, present in 1 of 5. CD was not associated with an increased risk of stroke or mortality at 30 day or 1 year. Post-TAVR stroke seems to be because of mechanisms other than CD.
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