Clinical Bioprosthetic Heart Valve Thrombosis After Transcatheter Aortic Valve Replacement

Background: Transcatheter aortic valve replacement has proved its safety and effectiveness in intermediate- to high-risk and inoperable patients with severe aortic stenosis. However, despite current guideline recommendations, the use of transcatheter aortic valve replacement (TAVR) to treat severe aortic valve stenosis caused by degenerative leaflet thickening and calcification has not been widely adopted in low-risk patients. This reluctance among both cardiac surgeons and cardiologists could be due to concerns regarding clinical and subclinical valve thrombosis. Stent performance alongside increased aortic root and leaflet stresses in surgical bioprostheses has been correlated with complications such as thrombosis, migration and structural valve degeneration. Materials and Methods: Self-expandable catheter-based aortic valve replacement (Medtronic, Minneapolis, MN, USA), which was received by patients who developed transcatheter heart valve thrombosis, was investigated using high-resolution biomodelling from computed tomography scanning. Calcific blocks were extracted from a 250 CT multi-slice image for precise three-dimensional geometry image reconstruction of the root and leaflets. Results: Distortion of the stent was observed with incomplete cranial and caudal expansion of the device. The incomplete deployment of the stent was evident in the presence of uncrushed refractory bulky calcifications. This resulted in incomplete alignment of the device within the aortic root and potential dislodgment. Conclusion: A Finite Element Analysis (FEA) investigation can anticipate the presence of calcified refractory blocks, the deformation of the prosthetic stent and the development of paravalvular orifice, and it may prevent subclinical and clinical TAVR thrombosis. Here we clearly demonstrate that using exact geometry from high-resolution CT scans in association with FEA allows detection of persistent bulky calcifications that may contribute to thrombus formation after TAVR procedure.

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Leaflet immobility and thrombosis in transcatheter aortic valve replacement

European Heart Journal ◽

10.1093/eurheartj/ehaa542 ◽

2020 ◽

Vol 41 (33) ◽

pp. 3184-3197

Author(s):

Arnold C T Ng ◽

David R Holmes ◽

Michael J Mack ◽

Victoria Delgado ◽

Raj Makkar ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Antiplatelet Therapy ◽

Valve Replacement ◽

Heart Valve ◽

Transcatheter Aortic Valve Replacement ◽

Thrombus Formation ◽

Transcatheter Aortic Valve ◽

Transcatheter Heart Valve ◽

Valve Thrombosis

Abstract Transcatheter aortic valve replacement (TAVR) has grown exponentially worldwide in the last decade. Due to the higher bleeding risks associated with oral anticoagulation and in patients undergoing TAVR, antiplatelet therapy is currently considered first-line antithrombotic treatment after TAVR. Recent studies suggest that some patients can develop subclinical transcatheter heart valve (THV) thrombosis after the procedure, whereby thrombus forms on the leaflets that can be a precursor to leaflet dysfunction. Compared with echocardiography, multidetector computed tomography is more sensitive at detecting THV thrombosis. Transcatheter heart valve thrombosis can occur while on dual antiplatelet therapy with aspirin and thienopyridine but significantly less with anticoagulation. This review summarizes the incidence and diagnostic criteria for THV thrombosis and discusses the pathophysiological mechanisms that may lead to thrombus formation, its natural history, potential clinical implications and treatment for these patients.

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Serial Imaging Assessment of Clinical Valve Thrombosis After Transcatheter Aortic Valve Replacement With LOTUS Edge

JACC Cardiovascular Interventions ◽

10.1016/j.jcin.2020.11.001 ◽

2020 ◽

Author(s):

Noriaki Moriyama ◽

Shohei Yokota ◽

Koki Shishido ◽

Futoshi Yamanaka ◽

Eiji Koyama ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Serial Imaging ◽

Transcatheter Aortic Valve ◽

Valve Thrombosis

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Real-World Experience With the SAPIEN 3 Ultra Transcatheter Heart Valve: A Propensity-Matched Analysis From the United States

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.121.010543 ◽

2021 ◽

Vol 14 (9) ◽

Author(s):

Tamim M. Nazif ◽

Thomas J. Cahill ◽

David Daniels ◽

James M. McCabe ◽

Mark Reisman ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Clinical Outcomes ◽

Valve Replacement ◽

Heart Valve ◽

Transcatheter Aortic Valve Replacement ◽

Transcatheter Aortic Valve ◽

Transcatheter Heart Valve ◽

Sapien 3 ◽

Transcatheter Valve

Background: Paravalvular regurgitation (PVR) after transcatheter aortic valve replacement is associated with adverse clinical outcomes. The SAPIEN 3 Ultra (Ultra) is a new generation balloon-expandable transcatheter heart valve with a modified external skirt that is designed to reduce PVR, but reports of clinical and echocardiographic outcomes are limited. The aim of this study was to compare short-term outcomes of patients undergoing transcatheter aortic valve replacement with the Ultra and the original SAPIEN 3 (S3) transcatheter heart valve in a large national registry. Methods: Data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was used to compare patients who underwent elective, transfemoral transcatheter aortic valve replacement with the Ultra or S3 transcatheter heart valve. Clinical and echocardiographic outcomes were analyzed in a propensity-matched cohort at discharge and 30 days. Results: Patients who underwent transcatheter aortic valve replacement with Ultra (N=1324) from January 2019 to February 2020 were propensity score–matched with patients treated with S3 (N=32 982) during the same period, resulting in 1324 matched pairs. There was no difference in the rate of device success between patients treated with Ultra and S3 (97.1% versus 98.0%, P =0.11). At hospital discharge, PVR was significantly reduced with Ultra compared with S3, with mild PVR in 9.0% versus 13.9% and moderate or greater PVR in 0.1% versus 0.4% (overall P <0.01). At 30 days, there were no differences between Ultra and S3 recipients in the rates of all-cause mortality or stroke (1.8% versus 2.8%, P =0.10), major vascular complications (1.1% versus 1.0%, P =0.84), or permanent pacemaker implantation (6.4% versus 6.2%, P =0.81). Conclusions: In this propensity-matched analysis from the Transcatheter Valve Therapy Registry, the Ultra transcatheter heart valve was associated with similar procedural and 30-day clinical outcomes, but reduced incidence of PVR, compared with S3. The clinical benefit of less PVR should be evaluated in longer-term studies.

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Pathologic confirmation of valve thrombosis detected by four-dimensional computed tomography following valve-in-valve transcatheter aortic valve replacement

Global Cardiology Science and Practice ◽

10.21542/gcsp.2017.15 ◽

2017 ◽

Vol 2017 (2) ◽

Author(s):

Ambarish Gopal ◽

Nathalia Ribeiro ◽

John J Squiers ◽

Elizabeth M Holper ◽

Michael Black ◽

...

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Thrombus Formation ◽

Imaging Modality ◽

4D Ct ◽

Transcatheter Aortic Valve ◽

Valve Thrombosis

A major concern regarding transcatheter aortic valve replacement (TAVR) is leaflet thrombosis. Four-dimensional computed tomography (4D-CT) is the preferred imaging modality to evaluate patients with suspected valve thrombosis. To date, the abnormal findings visualized by 4D-CT suggestive of leaflet thrombosis have lacked pathologic confirmation from a surgically explanted valve in a surviving patient. Herein, we provide pathologic confirmation of thrombus formation following surgical explantation of a thrombosed TAVR prosthesis that was initially identified by 4D-CT.

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