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Clinical Valve Thrombosis and Subclinical Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Is There a Need for a Patient-Tailored Antithrombotic Therapy?

ABSTRACT: Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis at increased surgical risk. Antithrombotic therapy after TAVR aims to prevent transcatheter heart valve (THV) thrombosis, in which two different entities have to be recognized: clinical valve thrombosis and subclinical leaflet thrombosis. In clinical valve thrombosis, obstructive thrombus formation leads to an increased transvalvular gradient, often provoking heart failure symptoms. Subclinical leaflet thrombosis is most often an incidental finding, characterized by a thin layer of thrombus covering the aortic side of one or more leaflets; it is also referred to as Hypo-Attenuating Leaflet Thickening (HALT) as described on multi-detector computed tomography (MDCT) imaging. This phenomenon may also affect leaflet motion and is then classified as Hypo-Attenuation affecting Motion (HAM). Even in case of HAM, the transvalvular pressure gradient remains within normal range and does not provoke heart failure symptoms. Whereas, clinical valve thrombosis requires treatment, the clinical impact and need for intervention in subclinical leaflet thrombosis is still uncertain. Oral anticoagulant therapy protects against and resolves both clinical valve thrombosis and subclinical leaflet thrombosis; however, large-scale randomized clinical trials studying different antithrombotic strategies after TAVR are still under way. This review article summarizes the currently available data within the field of transcatheter aortic valve/leaflet thrombosis and discusses the need for a patient tailored antithrombotic approach.

SUBMITTER: Rosseel L

PROVIDER: S-EPMC6482296 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Clinical Valve Thrombosis and Subclinical Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Is There a Need for a Patient-Tailored Antithrombotic Therapy?

Rosseel Liesbeth L De Backer Ole O Søndergaard Lars L

Frontiers in cardiovascular medicine 20190418

Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis at increased surgical risk. Antithrombotic therapy after TAVR aims to prevent transcatheter heart valve (THV) thrombosis, in which two different entities have to be recognized: clinical valve thrombosis and subclinical leaflet thrombosis. In clinical valve thrombosis, obstructive thrombus formation leads to an increased transvalvular gradient, oft ...[more]

PMID: 31058168

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Project description:The impact of antithrombotic regimen and platelet inhibition extent on subclinical leaflet thrombosis (SLT) detected by cardiac multidetector computed tomography (MDCT) after transcatheter aortic valve replacement (TAVR) is not well established. Hypoattenuation affecting motion (HAM) has been proposed as a surrogate marker of SLT, and is characterized by hypoattenuated leaflet thickening (HALT) and concomitant reduction in leaflet motion (RELM). We sought to investigate (i) the prevalence of HAM and HALT after TAVR detected by MDCT, (ii) the predictors of SLT, (iii) the impact of oral anticoagulant (OAC) and platelet inhibition extent assessed by platelet reactivity index vasodilator stimulated phosphoprotein (PRI-VASP) and closure time adenosine diphosphate (CT-ADP) on SLT. Of 187 consecutive patients who underwent TAVR from 1 August 2017 to 31 March 2018, 90 of them had cardiac CT at relevant follow-up. Clinical, biological, echocardiographic, procedural characteristics and treatments were collected before, at discharge, and 1 year after TAVR. P2Y12 platelet inhibition extent and primary haemostasis disorders were investigated using platelet PRI-VASP and CT-ADP point-of-care assays. Eighty-five post-TAVR CTs out of 90 were ranked for clarity and assessed with sufficient diagnostic quality. HAM was evidenced in 13 patients (15.3%) and HALT in 30 patients (35%). Procedural characteristics, including aortic valve calcium score, annulus size, or procedural heparin regimens, were equivalent between groups. Likewise, no impact of P2Y12 inhibition (PRI-VASP) nor primary haemostasis disorders (CT-ADP) on SLT could be evidenced. No impact of SLT on valve deterioration evaluated by transthoracic echocardiography (TTE) and clinical events could be established at 12 months follow-up. By multivariate analysis, lack of oral anticoagulant therapy at discharge (HR 12.130 CI 95% (1.394-150.582); p = 0.028) and higher haemoglobin levels were evidenced as the sole independent predictors of SLT. In four patients with HAM, MDCT follow-up was obtained after initiation of OAC therapy and showed a complete regression of HAM. SLT was evidenced in a sizeable proportion of patients treated by TAVR and was mainly determined by the lack of oral anticoagulant therapy. Conversely, no impact of platelet inhibition extent on SLT could be evidenced.

Dataset Information

Clinical Valve Thrombosis and Subclinical Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Is There a Need for a Patient-Tailored Antithrombotic Therapy?

Publications

Clinical Valve Thrombosis and Subclinical Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Is There a Need for a Patient-Tailored Antithrombotic Therapy?

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