Aortic Arch Morphology and Cerebrovascular Accidents After Transfemoral Transcatheter Aortic Valve Implantation.

Cerebrovascular accidents (CVA) after transcatheter aortic valve implantation (TAVI) remain a major concern. However, the impact of aortic arch morphology has not been investigated in this context. To address this gap, consecutive patients undergoing transfemoral TAVI between March 2009 and January 2025 were analysed. Aortic arch morphology was assessed on preprocedural computed tomography scans, including measurements of arch angle, presence of calcification and soft plaques. Patients were classified as having an acutely angled (gothic, angle ≤ 138°) aortic arch or a round (romanesque, angle > 138°) arch. The primary endpoint was the occurrence of CVA within 30 days following TAVI. A total of 1248 patients with a mean age of 81 ± 6 years (44% female) were studied. CVA occurred in 38 patients (3.0%) within 30 days. Notably, patients who experienced CVA had a significantly higher prevalence of a round arch (89% versus 72%, p = 0.021) and soft plaques along the outer curvature (45% versus 26%, p = 0.010). Other predictors of CVA included peripheral arterial disease (29% versus 12%, p = 0.002) and implantation of more than 1 transcatheter heart valve (11% versus 2%, p < 0.001). Interestingly, use of cerebral protection devices did not reduce stroke rates. In conclusion, an acutely angled (gothic) arch was not associated with increased risk for CVA within 30 days after TAVI. Instead, a round arch and soft plaques along the outer curvature were associated with more strokes. Such patients may benefit from careful advancement of the valve catheter when crossing the aortic arch or an alternative (transapical, direct aortic) access route.