Periprocedural cerebrovascular events after transcatheter aortic valve implantation: a systematic review and meta-analysis

Background Despite improvements in the safety of transcatheter aortic valve implantation (TAVI), cerebrovascular events (CVE) remain a clinically significant concern. Purpose This meta-analysis aims to evaluate the incidence, associated predictors of CVE, and their impact on major clinical outcomes in patients following TAVI. Methods and results A comprehensive literature search of PubMed, Cochrane, and Embase databases was conducted to identify relevant studies reporting CVE up to 30 days post-procedure. The primary endpoint of the present meta-analysis was the incidence of periprocedural CVE after TAVI. Secondary endpoints included in-hospital, 30-day, and one-year mortality rates in patients who experienced early CVEs after TAVI. We also evaluated patient and procedure-related predictors of CVEs, including history of stroke, atrial fibrillation (AF), peripheral artery disease (PAD), chronic kidney disease (CKD), type of valve (self-versus balloon-expandable valves), predilatation, transapical approach, and Valve-in-Valve technique. A meta-analysis with odds ratio (OR) and risk ratio (RR) was performed using random effects model, and heterogeneity was assessed using the I2 statistic. Results A total of 143 studies encompassing 804,534 patients were included in the meta-analysis. The pooled occurrence of CVE after TAVR was 2.6% (95% CI:2.4%-2.8%). CVE after TAVR were associated with >3 times greater risk of in-hospital mortality (odds ratio [OR] 3.68, 95% CI: 3.16 - 4.30), >5 times greater risk of 30-day mortality (OR 5.22, 95% CI: 4.25 - 6.41) and 3 times greater risk of 1year mortality (OR 2.99, 95% CI: 2.19 - 4.10). Meta-regression results indicated a significant reduction in stroke incidence based on study publication year (p=0.038). Significant predictors of CVE included prior stroke (RR: 1.61; 95%CI: 1.31 – 1.76), peripheral artery disease (PAD) (RR: 1.24; 95%CI: 1.11 – 1.61), chronic kidney disease (CKD) (RR: 1.27; 95%CI: 1.10 – 1.45), as well as procedural characteristics such as self-expandable valve implantation (RR: 1.63; 95%CI: 1.23 – 1.46). In contrast, no significant risk increase was observed in atrial fibrillation, pre-dilatation, transapical approach, or valve-in-valve procedures Conclusions Post-procedure CVE following TAVI remain a significant and potentially preventable source of patient mortality. These findings serve as an initial step toward guiding preventive strategies, such as the use of embolic protection devices in patients at higher risk.