Incidence, Predictors, and Mid-Term Outcomes of Possible Leaflet Thrombosis After TAVR

Yanagisawa, Ryoji; Hayashida, Kentaro; Yamada, Yoshitake; Tanaka, Makoto; Yashima, Fumiaki; Inohara, Taku; Arai, T.; Kawakami, Takashi; Maekawa, Yuichiro; Tsuruta, Hikaru; Itabashi, Yuji; Murata, Mitsushige; Sano, Motoaki; Okamoto, Kazuma; Yoshitake, Akihiro; Shimizu, Hideyuki; Jinzaki, Masahiro; Fukuda, Keiichi

doi:10.1016/j.jcmg.2016.11.005

Cited by 150 publications

(116 citation statements)

References 25 publications

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“…However, HALT and RLM were noted in patients receiving ongoing anticoagulation therapy, indicating that anticoagulation therapy is not a guarantee against these phenomena. This finding is supported by findings of a recent larger series of bioprosthetic valves …”

Section: Discussionsupporting

confidence: 86%

Hypo‐Attenuated Leaflet Thickening and Reduced Leaflet Motion in Sutureless Bioprosthetic Aortic Valves

Dalén

Sartipy

Cederlund

et al. 2017

JAHA

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BackgroundThe prevalence of hypo‐attenuated leaflet thickening (HALT) and reduced leaflet motion (RLM) is unknown in surgically implanted bioprostheses because systematic investigation of HALT and/or RLM is limited to a few catheter‐based valves. The aim of this study was to investigate the prevalence of HALT and RLM by cardiac computed tomography in patients who underwent surgical aortic valve replacement and received a Perceval sutureless aortic valve bioprosthesis.Methods and ResultsThis was a single‐center prospective observational study that included 47 patients (83.5% of the total number of implantations) who underwent surgical aortic valve replacement with implantation of the Perceval sutureless bioprosthesis (LivaNova PLC, London, UK) at Karolinska University Hospital in Stockholm, Sweden from 2012 to 2016 and were studied by cardiac computed tomography. Cardiac computed tomography was performed at a median of 491 days (range 36–1247 days) postoperatively. HALT was found in 18 (38%) patients and RLM in 13 (28%) patients. All patients with RLM had HALT. Among patients with HALT, 5 out of 18 patients (28%) were treated with anticoagulation (warfarin or any novel oral anticoagulant) at the time of cardiac computed tomography. Among patients with RLM, 3 out of 13 patients (23%) were treated with anticoagulation.Conclusions HALT and RLM were prevalent in the surgically implanted Perceval sutureless aortic valve bioprosthesis. Both HALT and RLM were found in patients with ongoing anticoagulation treatment. Whether these findings are associated with adverse events needs further study.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02671474.

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Section: Discussionsupporting

confidence: 86%

Hypo‐Attenuated Leaflet Thickening and Reduced Leaflet Motion in Sutureless Bioprosthetic Aortic Valves

Dalén

Sartipy

Cederlund

et al. 2017

JAHA

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“…Pressure differences naturally increase as the valve opening becomes more limited; one study reported that 16% of patients who were asymptomatic but had reduced leaflet motion on CT had a peak pressure difference of 20 mm Hg or greater 14. However, there are some cases where echocardiography does not demonstrate any significant increase in valvular pressure difference 4. Yanagisawa et al reported that the D-dimer level was significantly higher in a group of patients with HALT observed 6 months postoperatively than in the group without (2.3 vs 1.1 mg/mL, p=0.002) 4.…”

Section: Clinical Findingsmentioning

confidence: 99%

“…However, there are some cases where echocardiography does not demonstrate any significant increase in valvular pressure difference 4. Yanagisawa et al reported that the D-dimer level was significantly higher in a group of patients with HALT observed 6 months postoperatively than in the group without (2.3 vs 1.1 mg/mL, p=0.002) 4. Elevated D-dimer levels may serve as a reference indicator in cases of suspected HALT.…”

Section: Clinical Findingsmentioning

confidence: 99%

“…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. These facts suggest the involvement of blood flow stagnation near the valve, regional low flow rates and other factors important for thrombus formation, but these have not definitively been established as risk factors.…”

Section: Why Does Subclinical Leaflet Thrombosis Occur?mentioning

confidence: 99%

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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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“…Leaflet thrombosis in particular can be identified with Computed Tomography (CT) imaging 5, 6 . Many in-vivo clinical studies have tried to identify possible causes leading to leaflet thrombosis such as retention of blood flow and stasis in the sinuses and at the base of the leaflets 7–9 , lower implants of TAVs 7, 8 , under-expansion and asymmetry of the TAV 8 , incomplete TAV apposition to the aortic wall 9, 10 , the metallic frame of the TAV 9, 10 and other conditions.…”

Section: Introductionmentioning

confidence: 99%

Sinus Hemodynamics Variation with Tilted Transcatheter Aortic Valve Deployments

et al. 2018

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Leaflet thrombosis is a complication associated with transcatheter aortic valve (TAV) replacement (TAVR) correlated with sinus flow stasis. Sinus hemodynamics are important because they dictate shear stress and washout necessary to avoid stasis on TAV leaflets. Sinus flow is controlled by TAV axial deployment position but little is known regarding TAV axis misalignment effect. This study aims to elucidate TAV angular misalignment with respect to aortic root axis effect on sinus flow stasis potentially leading to leaflet thrombosis. Sinus hemodynamics were assessed in vitro using particle-image velocimetry in three different angular misalignments with respect to aorta axis: untilted, tilted away from the sinus and tilted towards sinus. A 26 mm Edwards SAPIEN3 was implanted in a 3D printed model of an anatomically realistic aortic root. TAV hemodynamics, sinus vortex tracking, leaflet shear stress probability density functions, and sinus blood time to washout were calculated. While pressure gradients differed insignificantly, blood velocity and vorticity decreased significantly in both tilted cases sinuses. Shear stress probability near the leaflet decreases with tilt indicating stasis. TAV tilted away from the sinus is the most unfavorable scenario with poor washout. TAV axial misalignment adds to factors list that could influence leaflet thrombosis risk through modifying sinus hemodynamics and washout.

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Incidence, Predictors, and Mid-Term Outcomes of Possible Leaflet Thrombosis After TAVR

Cited by 150 publications

References 25 publications

Hypo‐Attenuated Leaflet Thickening and Reduced Leaflet Motion in Sutureless Bioprosthetic Aortic Valves

Hypo‐Attenuated Leaflet Thickening and Reduced Leaflet Motion in Sutureless Bioprosthetic Aortic Valves

Subclinical leaflet thrombosis after transcatheter aortic valve implantation

Sinus Hemodynamics Variation with Tilted Transcatheter Aortic Valve Deployments

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