Association Between Transcatheter Aortic Valve Replacement and Early Postprocedural Stroke

Importance: Reducing postprocedural stroke is important to improve the safety of transcatheter aortic valve replacement (TAVR). Objective: This study evaluated the trends of stroke occurring within 30 days after the procedure during the first 5 years TAVR was used in the United States, the association of stroke with 30-day mortality, and the association of medical therapy with 30-day stroke risk. Design, Setting, and Participants: Retrospective cohort study including 101 430 patients who were treated with femoral and nonfemoral TAVR at 521 US hospitals in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry from November 9, 2011, through May 31, 2017. Thirty-day follow-up ended June 30, 2017. Exposures: TAVR. Main Outcomes and Measures: The rates of 30-day transient ischemic attack and stroke were assessed. Association of stroke with 30-day mortality and association of antithrombotic medical therapies with postdischarge 30-day stroke were assessed with a Cox proportional hazards model and propensity-score matching, respectively. Results: Among 101 430 patients included in the study (median age, 83 years interquartile range IQR, 76-87 years; 47 797 women 47. 1%; and 85 147 patients 83. 9% treated via femoral access), 30-day postprocedure follow-up data was assessed in all patients. At day 30, there were 2290 patients (2. 3%) with a stroke of any kind (95% CI, 2. 2%-2. 4%), and 373 patients (0. 4%) with transient ischemic attacks (95% CI, 0. 3%-0. 4%). During the study period, 30-day stroke rates were stable without an increasing or decreasing trend in all patients (P for trend =. 22) and in the large femoral access subgroup (P trend =. 47). Among cases of stroke within 30 days, 1119 strokes (48. 9%) occurred within the first day and 1567 (68. 4%) within 3 days following TAVR. The occurrence of stroke was associated with a significant increase in 30-day mortality: 383 patients (16. 7%) of 2290 who had a stroke vs 3662 patients (3. 7%) of 99 140 who did not have a stroke died (P <. 001; risk-adjusted hazard ratio HR, 6. 1 95% CI, 5. 4-6. 8; P <. 001). After propensity-score matching, 30-day stroke risk was not associated with whether patients in the femoral cohort were (0. 55%) or were not (0. 52%) treated with dual antiplatelet therapy at hospital discharge (HR, 1. 04; 95% CI, 0. 74-1. 46) nor was it associated with whether patients in the nonfemoral cohort were (0. 71%) or were not (0. 69%) treated with dual antiplatelet therapy (HR, 1. 02; 95% CI, 0. 54-1. 95). Similarly, 30-day stroke risk was not associated with whether patients in the femoral cohort were (0. 57%) or were not (0. 55) treated with oral anticoagulant therapy at hospital discharge (HR, 1. 03; 95% CI, 0. 73-1. 46) nor was it associated with whether patients in the nonfemoral cohort were (0. 75%) or were not (0. 82%) treated with an oral anticoagulant (HR, 0. 93; 95% CI, 0. 47-1. 83). Conclusions and Relevance: Between 2011 and 2017, the rate of 30-day stroke following transcatheter aortic valve replacement in a US registry population remained stable.