CASE REPORT European Journal of Cardio-Thoracic Surgery 52 (2017) 998–999 doi:10.1093/ejcts/ezx226 Advance Access publication 14 July 2017 Cite this article as: Voss S, Nöbauer C, Lange R, Bleiziffer S. Cerebral protection during transcatheter aortic valve implantation in an extreme high-risk patient. Eur J Cardiothorac Surg 2017;52:998–9. Cerebral protection during transcatheter aortic valve implantation in an extreme high-risk patient Stephanie Voss*, Christian Nöbauer, Rüdiger Lange and Sabine Bleiziffer Department of Cardiovascular Surgery, German Heart Center Munich, Clinic at the Technical University, Munich, Germany * Corresponding author. Department of Cardiovascular Surgery, German Heart Center Munich, Clinic at the Technical University, Munich, Germany. Tel: +49-89-12182854; fax: +49-89-12184113; e-mail: email@example.com (S. Voss). Received 11 April 2017; received in revised form 17 May 2017; accepted 31 May 2017 Abstract Stroke during transcatheter aortic valve replacement is one of the most feared complications. New technologies have been developed, attempting to prevent cerebral embolization of thrombotic and calcific debris. We report a 78-year-old patient (EuroSCORE log 45.6%, STS Stroke Score 5.1%) with calcific aortic stenosis at particular risk for cerebrovascular accidents. The patient underwent transapical transcatheter aortic valve replacement using the dual filter-based Claret SentinelTM Device for cerebral protection. Claret Sentinel Device use was associated with capture of macroscopic debris. Postoperatively, no neurological deficits could be detected by the National Institutes of Health Stroke Scale and modified Rankin scale. Keywords: TAVR • Cerebral embolic protection CASE for recurrent neurological events, we applied cerebral protection using the CSD. Preoperative evaluation included DW-MRI and assessment by a neurologist (National Institutes of Health Stroke Scale and modified Rankin scale). Baseline examination revealed partial gaze palsy and reduced muscular strength of the left extremities (National Institutes of Health Stroke Scale: 3; modified Rankin scale: 3). These findings were consistent with DW-MRI, which illustrated former middle cerebral artery infarctions on the right side and cerebellar infarctions. We started placing a 6-Fr sheath in the right radial artery (Video 1). After flushing the CSD, the system was delivered over a standard 0.014in (0.036 mm)-coronary guide wire. Before deploying both filters, arch and cerebrovascular anatomy were assessed by an aortic arch aortogram. The CSD was advanced to the brachiocephalic trunk and the proximal filter was deployed. The distal filter was developed in the left common carotid artery. Then, we performed A 78-year-old man presented with symptomatic aortic calcific stenosis and reduced left ventricular ejection fraction (30%). The patient underwent CABG in 1999, followed by multiple percutaneous coronary interventions. Additionally, the patient suffered from chronic kidney disease due to renal artery stenosis and middle cerebral artery strokes. A computed tomographic scan revealed diffuse calcification of the aorta, severe peripheral artery disease and an occlusion of the right and a moderate stenosis of the left internal carotid artery. The logistic EuroSCORE and STS Stroke Score were calculated to be 45.6% and 5.1%, respectively. Due to iliac artery calcifications, we decided on transapical TAVR. With a history of previous stroke and an extreme high risk Video 1: Intraoperative procedure. INTRODUCTION Despite the development of new-generation transcatheter aortic valve replacement (TAVR) valves and increased operator experience, stroke still remains a concern with recent data showing incidences of 5.5% at 30 days . Besides the risk of apparent neurological deficits, 77.5% of TAVR patients demonstrate silent cerebral infarctions in postoperative diffusion-weighted magnetic resonance imaging (DW-MRI) . These lesions were reported to increase the risk of a later clinically manifest stroke by 2–4 times . We present a case of an extreme high-risk patient undergoing TAVR using the Claret SentinelTM Device (CSD) for cerebral protection. C The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. V S. Voss et al. / European Journal of Cardio-Thoracic Surgery 999 Figure 1: (A) Filter after retrieval. (B) Captured embolic debris. a transapical implantation of an Edwards SAPIEN 3 (23 mm). By finishing the TAVR procedure, both filters were retrieved. Total operation time was 123 min; of the total time, 15 min was needed for CSD implantation. Fluoroscopy time for CSD implantation and retraction was 7.3 min, and the amount of contrast medium used was 15 ml. Filter indwelling time was 55 min. Exploration of both filters showed macroscopic evidence of captured embolic debris (Fig. 1). On postoperative Day 5, the patient was evaluated again by DWMRI and a neurologist. DW-MRI identified 1 new, small ischaemic lesion (2 1 mm), located in the left post-central gyrus (Fig. 2). Neurological examinations revealed no clinical stroke, showing the same neurological performance as preoperative. On the 7th postoperative day, the patient was discharged from the hospital. COMMENT Since its introduction in 2002, TAVR has become the treatment of choice in most high-risk patients. However, the occurrence of cerebral injury during TAVR still remains a problem. This issue cannot be ignored, as TAVR will be shifted increasingly to younger, lower risk patients. In our patient, at particular risk for recurrent stroke, we used the CSD to prevent cerebral embolization. Macroscopic embolic debris was found within both filters, which otherwise would have entered cerebral circulation. However, the system does not provide complete protection, leaving the left vertebral artery uncovered. Postoperative MRI showed 1 new, ischaemic lesion, without neurological deficits. To assess the efficacy of embolic protection on MRI outcomes, Pagnesi et al.  performed a meta-analysis, reporting no differences in new lesion number but a reduction in total new lesion volume using protection systems. However, a recent, randomized trial has not been able to confirm these significant MRI results. But this must be regarded critically. For instance, the sample size to evaluate MRI findings was too small and imaging time points postoperatively probably too broad (Days 2–7). Interestingly, the study provided significant differences in MRI findings, depending on the type of valve prosthesis . To address this particular issue and to re-evaluate the influence of cerebral protection on new MRI findings in a larger series, we designed the randomized PROTECT TAVI trial (NCT02895737), which currently is recruiting participants. Conflict of interest: none declared. REFERENCES     Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609–20. Pagnesi M, Martino EA, Chiarito M, Mangieri A, Jabbour RJ, Van Mieghem NM et al. Silent cerebral injury after transcatheter aortic valve implantation and the preventive role of embolic protection devices: A systematic review and meta-analysis. Int J Cardiol 2016; 221:97–106. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2013;44:2064–89. Kapadia SR, Kodali S, Makkar R, Mehran R, Lazar RM, Zivadinov R et al. Protection against cerebral embolism during transcatheter aortic valve replacement. J Am Coll Cardiol 2017;69:367–77. CASE REPORT Figure 2: (A) Baseline diffusion-weighted magnetic resonance imaging. (B) Postoperative diffusion-weighted magnetic resonance imaging.