Commissural misalignment independently predicts leaflet thrombosis after transcatheter aortic valve implantation

Abstract

Aims Transcatheter aortic valve implantation (TAVI) has become a minimally invasive alternative to surgical aortic valve replacement. Hypo-attenuated leaflet thickening (HALT)—a marker of subclinical leaflet thrombosis commonly detected by cardiac computed tomography (CT) after TAVI—may influence valve durability and function. The purpose of this study was to compare commissural alignment of the native and prosthetic aortic valves in cardiac CT in subjects with and without HALT and thereby identify commissural misalignment as potential predictor for leaflet thrombosis after TAVI. Methods and results In 170 subjects, 85 with and 85 without HALT in post-TAVI CT, commissural orientation of the prosthesis was determined comparing native and prosthetic aortic valve orientation in cardiac CT by measuring the commissural angle relative to the right coronary ostium in the aortic valve plane. For the prosthetic valve, any deviation ≤ 15° compared to the native valve was classified as “aligned”; 16–30° as “mild”, 31–45° as “moderate” and ≥ 45° as “severe” misalignment. Among subjects with HALT, median angular deviation was higher (36°, IQR 31°) than in the control group (29°, IQR 29°, p = 0.042). “Severe” misalignment was more frequent in subjects who developed HALT (n = 31, 37%) compared to the control group (n = 17, 20%, p = 0.013). In logistic regression analysis, more severe deviation (p = 0.015, OR = 1.02 per 1° deviation) and “severe” misalignment (p = 0.018, OR = 2.2) represented independent predictors for the occurrence of HALT after TAVI. Conclusion Subclinical leaflet thrombosis after TAVI is associated with commissural misalignment. Potential clinical advantages of obtaining commissural alignment remain to be systematically assessed. Graphical abstract Association of HALT with commissural misalignment after TAVI. HALT hypo-attenuated leaflet thickening, IQR interquartile range, TAVI transfemoral aortic valve replacement

Impact of commissural alignment on the hemodynamic performance of supra-annular self-expandable transcatheter aortic valves

“…Conversely, this eccentricity of the annulus is unlikely to be a contributing factor to the increased gradients progression given that it persisted after the matched comparison that included annular dimensions and eccentricity, but it cannot be excluded its relationship with the altered shear stress as has been previously suggested in computational models (12). Recent research by Jung et al (13) suggested that hypo-attenuated leaflet thickening (HALT) was more often detected among subjects with greater deviation of the commissures and, indeed, severe CMA resulted an independent predictor of HALT after TAVR (OR=2.2, p=0.018). Computational models have previously failed to demonstrate an increased platelet activation in this context (12) but blood flow stagnation has already been describe for balloon-expandable TAVR devices (1).…”

“…The trend to greater progression of aortic regurgitation in patients with moderate or severe CMA in our research could be explained by an impaired leaflet coaptation resulting from a more eccentric expansion of the device; it is known that annulus eccentricity conditions greater progression of regurgitation following selfexpandable devices more often that with balloon-expandable prosthesis (11), which could be exacerbated in case of CMA. This aspect added to the more adverse fluid dynamics with greater shear stress on the edge of the leaflets (12,13) could lead to a less efficient bioprosthetic leaflet closure during early diastole and explain the increased rate of central leak in our sample. Conversely, this eccentricity of the annulus is unlikely to be a contributing factor to the increased gradients progression given that it persisted after the matched comparison that included annular dimensions and eccentricity, but it cannot be excluded its relationship with the altered shear stress as has been previously suggested in computational models (12).…”

Clinical and structural outcomes of neocommissural alignment in transaxillary and transcarotid transcatheter aortic valve implantation with a self-expandable transcatheter heart valve

“…Raschpichler and colleagues 5 found that more than moderate CMA (>30°) with a balloon-expandable THV was independently associated with a relative aortic valve mean gradient increase of more than 50% from baseline to the first month control, and it might have an impact on the THV durability. More recently, Jung and colleagues 12 have recently reported that CMA is an independent risk factor for hypo-attenuated leaflet thickening, which serves as a marker of subclinical leaflet thrombosis.…”