Clinical and subclinical leaflet thrombosis in bioprosthetic aortic valves: A manifestation of Kounis syndrome?

Kounis, Nicholas G.; Grapsas, Nicholas; Soufras, George D.; Lianas, Dimitrios; Patsouras, Nicholas; Hahalis, George

doi:10.1016/j.ijcard.2016.03.130

Cited by 5 publications

(4 citation statements)

References 13 publications

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“…Others authors have suggested that the structure composition of the valves may play a differential role in thrombus formation. Whilst CoreValve porcine pericardium valve contains a nickel and titanium alloy, the Edward Sapien bovine pericardium valve has a polyethylene terephthalate skirt and cobalt chromium stent that could trigger allergic reaction, IgE antibody formation, and the coagulation cascade [20]. Finally, the contribution of paravalvular leak as a main determinant of platelet activation has recently be underlined [21].…”

Section: Discussionmentioning

confidence: 99%

Impact of Antithrombotic Regimen and Platelet Inhibition Extent on Leaflet Thrombosis Detected by Cardiac MDCT after Transcatheter Aortic Valve Replacement

Jimenez

Ohana

Marchandot

et al. 2019

JCM

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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.

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Section: Discussionmentioning

confidence: 99%

Impact of Antithrombotic Regimen and Platelet Inhibition Extent on Leaflet Thrombosis Detected by Cardiac MDCT after Transcatheter Aortic Valve Replacement

Jimenez

Ohana

Marchandot

et al. 2019

JCM

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“…Other possibilities include failure to achieve normal structuring of leaflet tissue making thrombosis likely to occur because the valve is folded before insertion, the valve is pushed and expanded by the balloon in the balloon-expandable type and in some cases, post-dilatation is added using the balloon 16. One report suggested the possibility of association of hypersensitive reaction to metal 19. The following patients are also reported to be likely to have thrombosis: patients with large valves,2 4 patients with an ejection fraction of 35% or lower,7 patients with a valve-in-valve placement,17 20 males,4 patients with a large sinus of Valsalva,4 patients not receiving anticoagulants2 and patients in whom incomplete or asymmetrical expansion occurred 20.…”

Section: Why Does Subclinical Leaflet Thrombosis Occur?mentioning

confidence: 99%

Subclinical leaflet thrombosis after transcatheter aortic valve implantation

Nakatani

2017

Heart

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Although clinically significant valve thrombosis after transcatheter aortic valve implantation (TAVI) is rare, the incidence of subclinical leaflet thrombosis has been reported to be up to about 10%-15%. It is mostly found 1-3 months after procedure in any type of transcatheter heart valve. Leaflet thrombosis is detected by high-resolution CT in the form of limited valve opening/closure and hypoattenuated leaflet thickening. Transthoracic or transesophageal echocardiography is capable of detecting limitations of valve motion, leaflet thickening, increased flow velocity across the valve. However, CT seems to be more sensitive than echocardiography to detect leaflet thrombosis. It can occur under dual antiplatelet therapy with aspirin and a thienopyridine but rarely occurs with anticoagulation with a vitamin K antagonist. A vitamin K antagonist is also helpful to resolve leaflet thrombosis. Several studies are ongoing to determine the effect of new oral anticoagulants (NOACs) in preventing major cardiovascular events. They will also provide useful information on whether NOACs prevent leaflet thrombosis.

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“…Kounis et al [29], commenting on a TAVR valve leaflet thrombosis case followed by stroke 3 years following implantation, suggested that a potential unifying mechanism could be a delayed hypersensitivity reaction to one or more components of the implanted valve or drugs administered during the implantation procedure (Kounis syndrome).…”

Section: Pathophysiologymentioning

confidence: 99%

Bioprosthetic Valve Thrombosis

et al. 2018

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Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), without conclusive evidence-based recommendations. The duration of anticoagulation following an episode of BPVT is unclear, and lifelong anticoagulation has been suggested. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, which have been poorly studied with regards to optimal treatment and prevention. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.

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Clinical and subclinical leaflet thrombosis in bioprosthetic aortic valves: A manifestation of Kounis syndrome?

Cited by 5 publications

References 13 publications

Impact of Antithrombotic Regimen and Platelet Inhibition Extent on Leaflet Thrombosis Detected by Cardiac MDCT after Transcatheter Aortic Valve Replacement

Impact of Antithrombotic Regimen and Platelet Inhibition Extent on Leaflet Thrombosis Detected by Cardiac MDCT after Transcatheter Aortic Valve Replacement

Subclinical leaflet thrombosis after transcatheter aortic valve implantation

Bioprosthetic Valve Thrombosis

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