Sex Differences in Stroke Following Transcatheter Aortic Valve Replacement and the Role of Embolic Protection Devices in Women

Several historical studies reported a higher rate of complications following transcatheter aortic valve replacement (TAVR) in women compared with men, especially major bleeding, vascular complications and stroke. More recent publications have demonstrated lower stroke rates following TAVR. The growing experience of modern TAVR operators played a crucial role in the reduction of early postprocedural stroke events. In addition, the improved transcatheter heart valve technology, the emphasis on a heart team-based selection process, and the inclusion of intermediate- and low-risk patients in the latest landmark randomised trials have all contributed to the lower stroke rates in contemporary trials. It is important to note, however, that at an individual level, stroke can significantly affect both quality of life and overall prognosis. Certain factors that increase the risk of periprocedural stroke include the distribution of calcification of native aortic valves, small aortic valve annuli, left ventricular dysfunction and fibrosis, and AF. These tend to occur more frequently in women. However, the role of cerebral embolic protection devices has not been shown to reduce procedure-related strokes in men or women. The overall incidence of factors predisposing to late-onset stroke is higher in women. Currently, there are no trials that have identified sex differences in the incidence and management of stroke following TAVR. This review aims to examine potential sex differences in the pathophysiology, preventive strategies and therapeutic options for stroke following TAVR.