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Transcatheter Aortic Valve Implantation and Subclinical and Clinical Leaflet Thrombosis: Multimodality Imaging for Diagnosis and Risk Stratification

ABSTRACT: In recent years, the phenomenon of subclinical leaflet thrombosis (SLT) in patients who have undergone transcatheter aortic valve implantation has become increasingly relevant. Hypo-attenuating leaflet thickening and hypo-attenuation affecting motion diagnosed by CT are the hallmarks of SLT, and their incidence varies depending on the intensity of screening. Whether these phenomena are a surrogate for leaflet thrombosis reducing valve durability and increasing the risk of stroke is still a matter of debate. Uncertainty remains over the optimal antithrombotic therapy after TAVI and the best treatment strategy is still not confirmed. Ongoing and future trials will provide more evidence about the best strategy for the prevention and treatment of SLT.

SUBMITTER: Martin M

PROVIDER: S-EPMC8546909 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Leaflet thrombosis after valve-in-valve transcatheter aortic valve implantation: a case series.

Project description:BackgroundValve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in degenerated surgical aortic valve replacement (SAVR) is an alternative to redo-SAVR. However, reports on leaflet thrombosis following ViV-TAVI are emerging and subclinical thrombosis has gained recent attention. Although the incidence of transcatheter heart valve (THV) thrombosis after TAVI for native aortic valve disease is low, current imaging studies suggest the incidence of subclinical THV thrombosis may be significantly higher. While anticoagulation strategies for THV patients for native aortic stenosis presenting with symptomatic obstructive thrombosis has been described, the optimal management and anticoagulation therapy of patients with THV thrombosis following ViV-TAVI are less evident.Case summaryWe report a case series of three patients presenting with early and late THV thrombosis after ViV-TAVI. Two patients presented clinically on single antiplatelet therapy and one patient presented with subclinical valve thrombosis whilst taking a non-vitamin K oral anticoagulation agent.DiscussionLeaflet thrombosis after ViV-TAVI is an important cause of THV degeneration and may present subclinically. Imaging modalities such as serial transthoracic echocardiograms and multidetector computerized tomography aid diagnosis and guide management. Patient-individualized risk- vs. -benefit prophylactic post-procedural oral anticoagulation may be indicated.

| S-EPMC7501921 | biostudies-literature

Numerical models for assessing the risk of leaflet thrombosis post-transcatheter aortic valve-in-valve implantation.

Project description:Leaflet thrombosis has been suggested as the reason for the reduced leaflet motion in cases of hypoattenuated leaflet thickening of bioprosthetic aortic valves. This work aimed to estimate the risk of leaflet thrombosis in two post-valve-in-valve (ViV) configurations, using five different numerical approaches. Realistic ViV configurations were calculated by modelling the deployments of the latest version of transcatheter aortic valve devices (Medtronic Evolut PRO, Edwards SAPIEN 3) in the surgical Sorin Mitroflow. Computational fluid dynamics simulations of blood flow followed the dry models. Lagrangian and Eulerian measures of near-wall stagnation were implemented by particle and concentration tracking, respectively, to estimate the thrombogenicity and to predict the risk locations. Most of the numerical approaches indicate a higher leaflet thrombosis risk in the Edwards SAPIEN 3 device because of its intra-annular implantation. The Eulerian approaches estimated high-risk locations in agreement with the wall sheer stress (WSS) separation points. On the other hand, the Lagrangian approaches predicted high-risk locations at the proximal regions of the leaflets matching the low WSS magnitude regions of both transcatheter aortic valve implantation models and reported clinical and experimental data. The proposed methods can help optimizing future designs of transcatheter aortic valves with minimal thrombotic risks.

| S-EPMC7813235 | biostudies-literature

Acute myocardial infarction associated with prosthetic valve leaflet thrombosis after transcatheter aortic valve implantation: a case report.

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| S-EPMC7793162 | biostudies-literature

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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| S-EPMC6482296 | biostudies-literature

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| S-EPMC7047047 | biostudies-literature

Leaflet perforation or tear late after transcatheter aortic valve implantation.

Project description: Not available

| S-EPMC8302883 | biostudies-literature

Subclinical Leaflets Thrombosis After Transcatheter Replacement of Bicuspid vs. Tricuspid Aortic Valve.

Project description:Background: Subclinical leaflet thrombosis (SLT) is an important sequela that compromises the durability of the bioprosthetic valve. Objectives: To better determine the effect of SLT in bicuspid aortic valve (BAV), we performed a retrospective assessment of CT-defined SLT in BAV and tricuspid aortic valve (TAV) stenotic patients. Methods: We consecutively collected patients undergoing the TAVR between August 2015 and March 2020 in our center. A total of 170 BAV and 201 TAV cases were enrolled. Multidetector computed tomography was performed within 30 days and at 1-year. Results: Twenty cases in the BAV group and 19 cases in the TAV group had hypoattenuated leaflet thickening (HALT) in 30 days (12.5 vs. 9.9%, p = 0.449), and 52 cases in BAV and 61 cases in TAV had the HALT (34.9 vs. 36.7%, p = 0.733) at 1-year follow-up. The mean aortic gradient (MAG) and effective orifice areas (EOA) values were comparable between the two groups at 30 days (HALT vs. no HALT; 10.8 ± 4.8 vs. 11.3 ± 6.0, p = 0.638; 1.6 ± 0.4 vs. 1.6 ± 0.3, p = 0.724), and still, no difference was observed in the MAG at 1-year (11.5 ± 5.6 vs. 10.6 ± 5.1, p = 0.164). However, the EOA at 1-year was statistically different between the two groups (1.5 ± 0.3 vs. 1.6 ± 0.4, p = 0.004). The multivariate logistic regression analysis demonstrated the anticoagulation and age as independent predictors both in the BAV and TAV groups at 1-year. There was no difference in clinical events between the HALT and no HALT group in relevant to BAV or TAV at 1-year follow-up. Conclusions: The presence of subclinical leaflet thrombosis defined by the CT was comparable between the BAV and TAV in the first year after the TAVR procedure. Age and anticoagulation were the independent predictors of the subclinical leaflet thrombosis at 1 year after the TAVR. There was no difference in relevant clinical events between the BAV and TAV groups at 1-year follow-up.

| S-EPMC8727537 | biostudies-literature

Clinical valve thrombosis post-transcatheter aortic valve implantation with hypoattenuating leaflet thickening in computed tomography: anticoagulation is the answer.

Project description: Not available

| S-EPMC8422332 | biostudies-literature

Cusp thrombosis of a self-expandable sutureless aortic valve treated by valve-in-valve transcatheter aortic valve implantation procedure: case report.

Project description:BackgroundSurgical implantation rates of bioprosthetic valves, especially the use of sutureless or rapid deployment valves, as well as the advent of transcatheter valve implantation (TAVR) have increased during the last decades mainly due to their excellent haemodynamic and clinical results. One common characteristic of all bioprosthetic types of surgical aortic valve replacement (SAVR) and TAVR is the risk of early degeneration, which leads to valve-dysfunction and is associated with higher rates of valve reinterventions. Recent studies have demonstrated that cusp thrombosis may play a role in early valve dysfunction. This case report is, to our knowledge, the first documentation on a successful treatment of early aortic valve (AV) degeneration of a sutureless AV thrombosis with a valve-in-valve (ViV) TAVR implantation.Case summaryA 77 years old woman was re-evaluated from the heart-team, which considered the following characteristics: severe impairment of mobility and frailty with an STS-score of 10.01% and a EuroSCORE II of 6.9%. Due to the high surgical risk for SAVR, we decided to perform a ViV-TAVR using a balloonexpandable bioprosthesis. The procedure was performed via transfemoral access under general anaesthesia using a 23 mm Edwards-Sapien 3 bioprosthesis without balloon-valvuloplasty and with nominal-volume dilation under rapid-pacing.DiscussionThe differentiation of bioprosthesis valve thrombosis, and hypoattenuating leaflet thickening vs. structural valve degeneration can be difficult, and a multimodality imaging approach, comprising trans-thoracic echocardiogram, transoesophageal echocardiography and computed tomography, useful. These investigations are very important to decide the right strategy of surgical valve replacement vs. TAVR.

| S-EPMC6426046 | biostudies-literature

Natural History of Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A 5-Year Follow-Up Study.

Project description:Background Subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) on multidetector computed tomography, is common after transcatheter aortic valve replacement (TAVR). Because little is known about the long-term natural history of subclinical HALT, we aimed to investigate this in patients who underwent TAVR without using additional anticoagulation. Methods and Results We retrospectively evaluated patients who underwent TAVR with the Edwards SAPIEN-XT at our institute between October 2013 and December 2015. Patients were grouped according to the presence or absence of HALT within 1 year after TAVR (HALT and No-HALT groups). The primary outcome, defined as the composite of all-cause mortality, heart failure readmission, and ischemic stroke, was compared. Valve performance was assessed over time by transthoracic echocardiography. Among 124 patients (men: 29.1%; median age, 85 years), 27 (21.8%) showed HALT on multidetector computed tomography within 1 year after TAVR. No patient required additional anticoagulation for treating HALT because of the absence of valve-related symptomatic deterioration. During the median follow-up period of 4.7 years (interquartile range, 4.0-5.6), the rate of primary outcome and valve performance was not statistically different between the 2 groups (37.0% versus 38.1%; log-rank test P=0.92; mean pressure gradient, 9 mm Hg [8-14 mm Hg] versus 10 mm Hg [7-15 mm Hg]; P=0.51, respectively). Conclusions Approximately 20% of patients after TAVR had HALT within 1 year; however, that did not change the risk of subsequent adverse cardiovascular events or the valve performance with statistical significance for up to 5 years despite no additional anticoagulation therapy.

| S-EPMC9851443 | biostudies-literature

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