Neosinus Flow Stasis Correlates With Thrombus Volume Post-TAVR

Trusty, Phillip M.; Sadri, Vahid; Madukauwa-David, Immanuel David; Funnell, Emelia; Kamioka, Norihiko; Sharma, Rahul; Makkar, Raj; Babaliaros, Vasilis; Yoganathan, Ajit P.

doi:10.1016/j.jcin.2019.03.022

Cited by 19 publications

(6 citation statements)

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“…A modified Virchow's triad has been proposed, encompassing (i) hypercoagulability at the bioprosthetic surface, (ii) leaflet surface damage and/or endothelial injury during device deployment, and (iii) stasis and turbulent flow ( 3 , 4 ). The formation of neosinuses between THV leaflets and the valve cage and between native leaflets and aortic wall creates semi-permeable barriers that lead to flow stasis and reduced washout forces ( Figure 1 ) ( 5 ). Factors including larger-sized or overexpanded balloon-expandable valves, low-deployment depth of self-expanding valves (particularly CoreValve Evolut, Medtronic), intra-annular valve position, small annular perimeter, valve-in-valve (ViV) TAVR for stented surgical valves, non-commissural alignment, low coronary washout, small sinus size, and reduced flow can increase thrombosis risk ( 6 – 8 ).…”

Section: Mechanismmentioning

confidence: 99%

Leaflet thrombosis in transcatheter aortic valve intervention: mechanisms, prevention, and treatment options

Koren,

Patel,

Chakravarty

et al. 2023

Front. Cardiovasc. Med.

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IntroductionTranscatheter aortic valve intervention (TAVR) has emerged as a promising alternative to surgical aortic valve replacement for patients with severe aortic stenosis. However, leaflet thrombosis has raised concerns about the long-term durability and outcomes of TAVR. This study aims to provide an overview of the mechanisms, prevention strategies, and treatment options for leaflet thrombosis in TAVR.Clinical evidenceLeaflet thrombosis refers to the formation of blood clots on bioprosthetic valve leaflets, leading to impaired leaflet mobility, early valve degeneration and dysfunction, and potential clinical implications. While the mechanisms underlying thrombus formation on valve leaflets are not fully understood, several factors, such as altered blood flow patterns within valve neosinuses, prothrombotic surfaces, and patient-related causes, have been implicated. Two distinct entities have been identified, namely, hypoattenuated leaflet thickening and restricted leaflet motion. Their occurrence appears dynamic over time and is related to the valve type. Imaging, including transesophageal echocardiography and multidetector computed tomography, plays a crucial role in the diagnosis and follow-up of leaflet thrombosis.Prevention and treatment optionsPreventing leaflet thrombosis requires a comprehensive and tailored approach involving identifying high-risk patients, close monitoring, and antithrombotic therapy. Antithrombotic therapy with dual antiplatelet agents or anticoagulation is commonly employed in TAVR patients, although the optimal regimen is yet to be defined. Novel antithrombotic agents, such as direct oral anticoagulants, are being investigated for their efficacy and safety in preventing leaflet thrombosis. When leaflet thrombosis is detected, treatment options include intensified antithrombotic therapy, valve-in-valve intervention, or balloon valvuloplasty. The long-term outcomes and impact of leaflet thrombosis on valve durability and patient prognosis are areas of ongoing research.SummaryLeaflet thrombosis in TAVR is a considerable complication affecting valve function and patient outcomes. Understanding the mechanisms underlying thrombus formation and implementing appropriate prevention strategies are essential for mitigating this risk. Treatment options aim to restore leaflet mobility and optimize valve performance. Further research is needed to establish standardized protocols for antithrombotic therapy, identify high-risk patient populations, and determine the long-term consequences of leaflet thrombosis on TAVR outcomes.

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Section: Mechanismmentioning

confidence: 99%

Leaflet thrombosis in transcatheter aortic valve intervention: mechanisms, prevention, and treatment options

Koren,

Patel,

Chakravarty

et al. 2023

Front. Cardiovasc. Med.

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“…12 This anatomy may predispose to regions of stasis and low-velocity blood flow. 6 For a given patient, the flow dynamics are governed by the relationship between the neosinus and the THV, with contributing characteristics including valve expansion, deployment depth, commissural alignment, coronary washout, sinus size, and flow. [13][14][15] Larger valve sizes and balloon-expandable valves have been demonstrated to be higher risk for leaflet thrombosis.…”

Section: Pathophysiologymentioning

confidence: 99%

“…Subclinical leaflet thrombosis (ie, the diagnosis of leaflet thrombosis via imaging without clinical manifestations or immediate sequelae, including asymptomatic patients with an elevated transvalvular gradient on echocardiography) is more common, affecting up to 15% of patients, depending on the time point of study and the diagnostic imaging modality used. The diagnostic modality most commonly used for detecting leaflet thrombosis is a gated cardiac computed tomography (CT; 4-dimensional [4-D] cardiac CT angiography), where it manifests as hypoattenuated leaflet thickening (HALT) associated with or without restricted leaflet motion (RLM) …”

Section: Introductionmentioning

confidence: 99%

“…The hemodynamics of blood flow in the neosinus are distinct from the native aortic valve, and washout of blood from the neosinus is restricted by the barrier formed by the native aortic valve leaflets . This anatomy may predispose to regions of stasis and low-velocity blood flow …”

Section: Introductionmentioning

confidence: 99%

“…The diagnostic modality most commonly used for detecting leaflet thrombosis is a gated cardiac computed tomography (CT; 4-dimensional [4-D] cardiac CT angiography), where it manifests as hypoattenuated leaflet thickening (HALT) associated with or without restricted leaflet motion (RLM). 6 The clinical significance of subclinical leaflet thrombosis remains uncertain, but concerns exist that it may progress to clinical valve thrombosis, thromboembolism, or represent the first stage of structural valve degeneration. 7 Leaflet thrombosis can be effectively prevented and treated by OAC, but the use of anticoagulation must be balanced against the ongoing risk of hemorrhage, especially in a population where elevated bleeding risk is common, and hemorrhagic complications are associated with adverse outcomes.…”

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confidence: 99%

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Subclinical Leaflet Thrombosis and Anticoagulation After Transcatheter Aortic Valve Replacement

et al. 2022

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IMPORTANCE Subclinical leaflet thrombosis affects approximately 15% of patients after transcatheter aortic valve replacement (TAVR). The pathophysiology and clinical significance of leaflet thrombosis remain incompletely understood. Defining the optimal management strategy in patients who are asymptomatic, including the role for oral anticoagulation (OAC), is a key challenge for the field.OBSERVATIONS Three recent randomized trials have evaluated the role of OAC in patients after TAVR. These studies have confirmed prior observational data suggesting that OAC is effective at prevention of subclinical leaflet thrombosis. Overall, however, OAC does not lead to a clinical benefit over the period studied, and in some patients may be harmful owing to bleeding risk. CONCLUSIONS AND RELEVANCEStrategies for identification of patients in whom the benefit of OAC outweighs the risks are required for optimization of long-term outcome after TAVR. This requires clearer insights into the mechanisms of asymptomatic leaflet thrombosis, its clinical significance, and patient-specific risks of bleeding and structural valve degeneration.

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Heart Valve Disease

Siems

2023

Heart Valves

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Neosinus Flow Stasis Correlates With Thrombus Volume Post-TAVR

Cited by 19 publications

References 1 publication

Leaflet thrombosis in transcatheter aortic valve intervention: mechanisms, prevention, and treatment options

Leaflet thrombosis in transcatheter aortic valve intervention: mechanisms, prevention, and treatment options

Subclinical Leaflet Thrombosis and Anticoagulation After Transcatheter Aortic Valve Replacement

Heart Valve Disease

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