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\begin{document}

\title{Letter to the Editor: Anatomical reasons for failure of dual-filter
cerebral embolic protection application in TAVR: A CT-based analysis}



\author[1]{Muhammad Ali Muzammil}%
\author[2]{Rahat Ahmed Memon}%
\author[3]{Satesh Kumar}%
\affil[1]{Dow University of Health Sciences}%
\affil[2]{Abington Memorial Hospital}%
\affil[3]{Shaheed Mohtarma Benazir Bhutto Medical College}%


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  \date{May 19, 2024}


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\textbf{TITLE:} Letter to the Editor: Anatomical reasons for failure of
dual-filter cerebral embolic protection application in TAVR: A CT-based
analysis

\textbf{ARTICLE TYPE:} letter to the editor

\textbf{CORRESPONDENCE:} 1. Muhammad Ali Muzammil

Contact; +92 3313657590 Email; muzammil200077@gmail.com

Institute: Dow University of Health Sciences, karachi

Address: A-49 Street No.8 Block:2 Chapal Sun city near kiran Hospital
Scheme\#33 Gulzar-e-hijri

\textbf{Co-Authors} ; 2. Rahat Ahmed Memon

Email: rahatahmed227@yahoo.com Contact: +12677091949

Institute: Abington Memorial Hospital

\section*{}

{\label{section}}

\textbf{3.} Satesh Kumar

Contact: +92-3325252902 Email: Kewlanisatish@gmail.com

Institute: Shaheed Mohtarma Benazir Bhutto Medical College Liyari,
Karachi

Address: Parsa citi Garden east, Karachi

\textbf{Words count:} 403

\textbf{Conflict of interest;} none

\textbf{Disclosure;} none

\textbf{Funding;} none

\textbf{Letter:}

To the Editor:

An article published recently by Stephanie Voss et
al.\textsuperscript{1} ``Anatomical reasons for failure of dual-filter
cerebral embolic protection application in TAVR: A CT-based analysis''
has interested us in it as it provides a vast amount of knowledge to its
readers. The authors did remarkable work in trying to explain the
relationship and tried to convey it as best they could. We would
certainly not hesitate to state that it was a pleasure to read such
incredible work by the authors. We agree with the authors that specific
anatomical reasons may lead to dual-filter cerebral embolic protection
failure. However, we would like to highlight a few points that would
improve the quality of the document by mentioning them.

Considering the limitation of the study, this study may raise concerns
as its design is retrospective and may be prone to reporting bias which
may lead to incongruous documentation; the results would be better if
they included data of present times. This study may also be jeopardized
because results may also show publication bias as included participants
are from one selected location; the results could be more accurate if
they had conducted a multicenter study design. In addition, the authors
in this article have missed to mention the history of calcification and
the different diameters in which the filter was placed, as other studies
have mentioned with proper diameters found in the
patient.\textsuperscript{2} We would also like to enlighten a point that
the authors could have mentioned in this study and explain which type of
stroke was found as they are two types of stroke, such as Acute or
sub-acute stroke, which has been mentioned in one
study.\textsuperscript{3} The authors intended to mention only the
history of strokes and strokes as a serious complication without
mentioning its type. Furthermore, this study has mentioned in its
limitation that they have not assessed any neurological outcome, which
is a major concern in this study as in one study they had assessed this
outcome and have mentioned that their neurological outcomes were better
as they found a significant amount of reduction in imaging markers of
cerebral infarction by using intraprocedural embolic protection during
TAVR.\textsuperscript{4} Another point that the authors should have
mentioned was the histopathology of the embolus as mentioned in one
study, which would have helped this study to interpret more reasons for
the failure of the dual filter cerebral embolic protection application
in TAVR.\textsuperscript{5}

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Voss S, Campanella C, Burri M, Trenkwalder T, Sideris K, Erlebach M,
  Ruge H, Krane M, Vitanova K, Lange R. Anatomical reasons for failure
  of dual-filter cerebral embolic protection application in TAVR: A
  CT-based analysis. J Card Surg. 2021 Dec;36(12):4537-4545. doi:
  10.1111/jocs.16025. Epub 2021 Sep 27. PMID: 34580919.
\item
  Voss S, Schechtl J, N\selectlanguage{ngerman}öbauer C, Bleiziffer S, Lange R. Patient
  eligibility for application of a two-filter cerebral embolic
  protection device during transcatheter aortic valve implantation: does
  one size fit all? Interact Cardiovasc Thorac Surg. 2020 Apr
  1;30(4):605-612. doi: 10.1093/icvts/ivz306. PMID: 31904829.
\item
  Demir OM, Iannopollo G, Mangieri A, Ancona MB, Regazzoli D, Mitomo S,
  Colombo A, Weisz G, Latib A. The Role of Cerebral Embolic Protection
  Devices During Transcatheter Aortic Valve Replacement. Front
  Cardiovasc Med. 2018 Oct 23;5:150. doi: 10.3389/fcvm.2018.00150. PMID:
  30406115; PMCID: PMC6205957.
\item
  Giustino G, Mehran R, Veltkamp R, Faggioni M, Baber U, Dangas GD.
  Neurological Outcomes With Embolic Protection Devices in Patients
  Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review
  and Meta-Analysis of Randomized~Controlled Trials. JACC Cardiovasc
  Interv. 2016 Oct 24;9(20):2124-2133. doi: 10.1016/j.jcin.2016.07.024.
  PMID: 27765306.
\item
  Van Mieghem NM, Schipper ME, Ladich E, Faqiri E, van der Boon R,
  Randjgari A, Schultz C, Moelker A, van Geuns RJ, Otsuka F, Serruys PW,
  Virmani R, de Jaegere PP. Histopathology of embolic debris captured
  during transcatheter aortic valve replacement. Circulation. 2013 Jun
  4;127(22):2194-201. doi: 10.1161/CIRCULATIONAHA.112.001091. Epub 2013
  May 7. PMID: 23652860.
\end{enumerate}

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