Gradient changes in bioprosthetic valve thrombosis: duration of anticoagulation and strategies to improve detection

Abstract

ObjectiveBioprosthetic valve thrombosis (BPVT) is increasingly recognised as a major cause of prosthetic dysfunction in the first years postimplantation. How early abnormal gradients can be detected prior to diagnosis and how fast they normalise with anticoagulant therapy is unknown. We set forth to (1) evaluate patterns of increase in gradients prior to BPVT diagnosis and (2) characterise time-course of response to anticoagulation.MethodsPatients treated with warfarin for BPVT (1999–2019) with clinically significant reduction of mean gradients (≥25%) were identified retrospectively. Recovery was defined as gradient decrease ≥50%, to postimplantation or to normal-range gradients per position, model and size. Time-to-BPVT (implantation—BPVT diagnosis), potential diagnostic delay (first abnormal gradient by position, model and size—BPVT diagnosis) and time-to-recovery (BPVT diagnosis—complete resolution) were recorded.Results77 patients were identified; 32 (42%) aortic (23 surgical—12 porcine, 11 pericardial; 9 transcatheter); 24 (31%) mitral; 21 (27%) tricuspid. Median time-to-BPVT was 24, 21 and 10 months, respectively. Potential diagnostic delay was median 21 months for aortic, 4 months for mitral, but 0 for tricuspid. Recovery was significantly faster in mitral than aortic (median 2.5 vs 4.8 months, p=0.038) and tricuspid (median 5.9 months, p=0.025) positions. Porcine aortic valves responded faster than pericardial aortic valves (median 2.9 vs 20.3 months, p=0.004).ConclusionGradients start to increase months before the clinical BPVT diagnosis. Recovery is faster in mitral and surgical aortic porcine valves; a longer warfarin trial seems indicated in tricuspid and surgical aortic pericardial valves.

European Neuroendocrine Tumor Society (ENETS) 2022 Guidance Paper for Carcinoid Syndrome and Carcinoid Heart Disease

“…• Bioprosthetic valves are the recommended option 73 • If early (< 3 years) bioprosthetic valve deterioration occurs, thrombus should be considered and evaluation with TOE or CCT should be performed. 77,78 Q9: "Nonsurgical" interventional options for CHD 8…”

“…5B If bioprosthetic valve gradients increase by 50%, there is new abnormal leaflet thickening, abnormal leaflet mobility or prosthetic regurgitation following anticoagulation cessation, anticoagulation should be restarted and bioprosthetic valves reassessed in 1–3 months 76 . 5B If early (< 3 years) bioprosthetic valve deterioration occurs, thrombus should be considered and evaluation with TOE or CCT should be performed 77,78 …”

Bioprosthetic Aortic Valve Thrombosis and Literature Review

“…The impact of subclinical BAV thrombosis on postprocedural outcomes, valve durability and function, as well as the risk of mortality and stroke remains uncertain [ 6 ]. Recently, prolonged subclinical BAV thrombosis with increased gradients has been recognized as a cause of valve failure years following implantation [ 5 , 9 ]. There are data supporting that elevated valvular gradients are present months before BAV thrombosis is diagnosed clinically, thus yearly echocardiographic surveillance and increased awareness could lead to earlier diagnosis and more effective therapy [ 5 ].…”

“…Although once considered rare, discrepancies between the doppler and catheter gradients of aortic valve prosthesis have been reported since the early 1990s [ 3 ]. Chronically elevated valvular gradients are hallmark findings and are often present long before symptom development and formal diagnosis [ 4 , 5 ]. As such, BAV thrombosis may be categorized as either subclinical or clinical [ 6 ].…”

“…Subclinical thrombosis in bioprosthetic surgical aortic valves (SAVI) appears to occur significantly less frequently and later when compared with transcatheter valves (TAVI) [ 5 , 7 ]. Furthermore, subclinical BAV thrombosis was historically deemed to occur primarily within 12 months following the implantation [ 5 , 7 , 8 ]. Subsequent observations have shown that BAV thrombosis may occur years following the prosthesis implantation [ 9 ].…”