Incomplete expansion of transcatheter aortic valves is associated with propensity for valve thrombosis

Khodaee, Farhan; Barakat, Mohammed; Abbasi, Moslem; Dvir, Danny; Azadani, Ali N.

doi:10.1093/icvts/ivz213

Cited by 36 publications

(26 citation statements)

References 26 publications

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“…At near valve closure, flow dynamics can be considered analogous to transient valve stenosis, whereby regurgitation is increasingly constrained until complete, motionless, closed-valve conditions occur. During brief crucial moments preceding valve closure, localized prothrombotic microenvironments may be relevant to generation of high velocity leakage jets, flow unsteadiness, valve flutter, cyclic variability of PDVA, turbulence, and excessive shear forces that may induce blood element damage [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. These influences may impact multiple valve types for:…”

Section: Resultsmentioning

confidence: 99%

“… conduction abnormalities,  reduced valve leaflet mobility, sub-clinical thrombosis [17,23,[26][27][28]30],  potential for pannus formation,  silent cerebral micro-infarction [24,25],  acute and sub-acute embolic stroke and other adverse cerebrovascular events including TIA [24,26],  cavitation and high intensity trans-cranial signals (HITS) [6].…”

Section: Resultsmentioning

confidence: 99%

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Violin plot data: A concerto of crucial information on valve thrombogenicity categorized in vitro by valve motion and inferred flow velocity

Scotten

Blundon

Deutsch

et al. 2019

Preprint

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Objectives: We hypothesize that prosthetic valve thrombogenic potential may be inferred by valve regional flow velocity. This metric was used to compare two clinical valves and two experimental prototypes. Methods: Four our clinical and experimental prototype valve models were tested in aortic and mitral sites under pulsatile circulation in a pulse duplicator. An optical approach measuring projected dynamic valve area to gauge valve motion was implemented. Pulsatile pressures and flow rates were measured by conventional techniques and a quasi-steady flow tester was used to measure valve leakage. Regurgitant flow velocity was derived using time-dependent volumetric flow rate / projected dynamic valve area. Since flow velocity and fluid shear force are related through flow velocity gradient, thrombogenic potential for valves that achieve near closure during the forward flow deceleration phase were determined as regurgitant flow velocities relative to the control mechanical valve regurgitant flow velocity of -126 m/s. Analysis of the flow velocity data made use of Vioplot R* and VISIO software packages to provide split violin plots that represent probability of recurrence of data. Results: Thrombogenic potential was made dimensionless and ranged between -0.45 and +1.0. Negative thrombogenic potentials arise when transient rebound of valve occluder is accompanied by water-hammer phenomena. Positive thrombogenic potentials occur during decelerating forward flow. Bioprostheses had lowest thrombogenic potential transient of 0.15. A mock-transcatheter aortic valve replacement incorporating by design a trivial paravalvular leak (~1.35 ml/s) demonstrated a high transient thrombogenic potential of 0.95. Conclusions: Our data reveals distinct thrombogenic potential profile differences between valve models. If our study methods are verifiable, the design of future valves may utilize currently available experimental tools to produce advanced devices with significantly reduced thrombogenic potential.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Violin plot data: A concerto of crucial information on valve thrombogenicity categorized in vitro by valve motion and inferred flow velocity

Scotten

Blundon

Deutsch

et al. 2019

Preprint

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“…Even in oval-shaped annuli, we did not register the phenomena of incomplete valve expansion. A recent study 25 showed that the incomplete expansion of the S3 valve occurs in cases with distinct balloon underfilling for valve expansion. The finding of higher pressure gradients, secondary to higher hemodynamic-relevant PVLs in the nOS cohort, may have consequences in regard to valve durability.…”

Section: Discussionmentioning

confidence: 99%

“…Even in oval-shaped annuli, we did not register the phenomena of incomplete valve expansion. A recent study 25 showed that the incomplete expansion of the S3 valve occurs in cases with distinct balloon underfilling for valve expansion. Oversized versus Non-oversized with SAPIEN 3 Valve Useini et al 451…”

Section: Discussionmentioning

confidence: 99%

Oversized versus Non-oversized Prosthesis: Midterm Outcomes after Transcatheter Aortic Valve Replacement Using SAPIEN 3 Valve

Useini

Beluli

Christ

et al. 2020

Thorac Cardiovasc Surg

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Background A certain degree of prosthesis oversizing is recommended for the SAPIEN 3 (S3; Edwards Lifesciences Corp., Irvine, California, United States) to ensure device success. We aimed to investigate midterm outcomes in patients who received oversized (OS) S3 valve after transapical–transcatheter aortic valve replacement (TA-TAVR). Methods Out of 122 patients with aortic stenosis who underwent TA-TAVR using S3 at our institution, 42 received OS prosthesis. We used computed tomography (CT) derived effective diameter to assess oversizing. We defined oversizing if the labeled diameter of the selected valve for implantation was ≥2 mm bigger than the effective annulus diameter calculated by the annulus area. We conducted a midterm follow-up and compared the OS cohort with the non-OS (nOS) cohort. Results The study groups showed similar risk score and age (STS [Society of Thoracic Surgery] score: 5.4 ± 3; mean age: 80.7 ± 5.7). The 30-day mortality was 7.1% in OS versus 2.4% in nOS. The 30-day all-stroke was 2.4% in OS versus 0% in nOS. The 1- and 3-year all-cause mortality were 28.5 and 42.8% in OS versus 21.9 and 26.8% in nOS, respectively. Midterm freedom from death and from cardiocerebral events was similar in both groups. Moderate/severe paravalvular leakage occurred in 0% in OS versus 5.4% in nOS. The postdilation rate was 7.1% in OS versus 15.3% in nOS. The rate of new permanent pacemaker implantation (PPI) was 15.7% in OS versus 9.3% in nOS. The STS score was detected as an independent predictor of mortality. Conclusion Oversizing reduces the risk of device failure and intraprocedural postdilation but increases the risk of PPI. Early and midterm morbidity and mortality after OS and nOS with S3 are comparable.

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“…between annulus and leaflet free edge, compared to both TAV and Sievers 0 and maximum strut deviation that is three-fold greater than devices deployed in TAV (Fig 3). Such deviations in expansion and alignment are thought to be associated with clinical complications [17][18][19][20]. Indeed, the loss of axisymmetry observed in devices deployed in Sievers 1 BAV, are unlikely to reconstitute normal flow and instead may impose eccentric jets that effect perfusion, which may manifest clinically as higher rates of stroke at 30 days compared to TAV [15].…”

Section: Plos Onementioning

confidence: 99%

Understanding TAVR device expansion as it relates to morphology of the bicuspid aortic valve: A simulation study

et al. 2021

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The bicuspid aortic valve (BAV) is a common and heterogeneous congenital heart abnormality that is often complicated by aortic stenosis. Although initially developed for tricuspid aortic valves (TAV), transcatheter aortic valve replacement (TAVR) devices are increasingly applied to the treatment of BAV stenosis. It is known that patient-device relationship between TAVR and BAV are not equivalent to those observed in TAV but the nature of these differences are not well understood. We sought to better understand the patient-device relationships between TAVR devices and the two most common morphologies of BAV. We performed finite element simulation of TAVR deployment into three cases of idealized aortic anatomies (TAV, Sievers 0 BAV, Sievers 1 BAV), derived from patient-specific measurements. Valve leaflet von Mises stress at the aortic commissures differed by valve configuration over a ten-fold range (TAV: 0.55 MPa, Sievers 0: 6.64 MPa, and Sievers 1: 4.19 MPa). First principle stress on the aortic wall was greater in Sievers 1 (0.316 MPa) and Sievers 0 BAV (0.137 MPa) compared to TAV (0.056 MPa). TAVR placement in Sievers 1 BAV demonstrated significant device asymmetric alignment, with 1.09 mm of displacement between the center of the device measured at the annulus and at the leaflet free edge. This orifice displacement was marginal in TAV (0.33 mm) and even lower in Sievers 0 BAV (0.23 mm). BAV TAVR, depending on the subtype involved, may encounter disparate combinations of device under expansion and asymmetry compared to TAV deployment. Understanding the impacts of BAV morphology on patient-device relationships can help improve device selection, patient eligibility, and the overall safety of TAVR in BAV.

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Incomplete expansion of transcatheter aortic valves is associated with propensity for valve thrombosis

Cited by 36 publications

References 26 publications

Violin plot data: A concerto of crucial information on valve thrombogenicity categorized in vitro by valve motion and inferred flow velocity

Violin plot data: A concerto of crucial information on valve thrombogenicity categorized in vitro by valve motion and inferred flow velocity

Oversized versus Non-oversized Prosthesis: Midterm Outcomes after Transcatheter Aortic Valve Replacement Using SAPIEN 3 Valve

Understanding TAVR device expansion as it relates to morphology of the bicuspid aortic valve: A simulation study

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