Subclinical Leaflet Thrombosis in Transcatheter and Surgical Bioprosthetic Valves

Makkar, Raj; Blanke, Philipp; Leipsic, Jonathon; Thourani, Vinod H.; Chakravarty, Tarun; Brown, David L.; Trento, Alfredo; Guyton, Robert A.; Babaliaros, Vasilis; Williams, Mathew; Jilaihawi, Hasan; Kodali, Susheel; George, Isaac; Lu, Michael T.; McCabe, James M.; Friedman, John D.; Smalling, Richard W.; Wong, S. Chiu; Yazdani, Shahram; Bhatt, Deepak L.; Bax, Jeroen J.; Kapadia, Samir; Herrmann, Howard C.; Mack, Michael J.; Leon, Martin B.

doi:10.1016/j.jacc.2020.04.043

Cited by 180 publications

(142 citation statements)

References 21 publications

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“…The relationship with leaflet thrombosis at longer-term follow-up is under active investigation. 39,40 The role of anticoagulation following SAVR or TAVR remains unclear and requires careful evaluation.…”

Section: Discussionmentioning

confidence: 99%

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies

Thourani¹,

Edelman

Holmes

et al. 2021

Innovations�(Phila)

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Objective There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons. Methods Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year. Results Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios. Conclusions In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient’s aortic valve disease.

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Section: Discussionmentioning

confidence: 99%

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies

Thourani¹,

Edelman

Holmes

et al. 2021

Innovations�(Phila)

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“…Dr Jonathon Leipsic spoke eloquently on the results and implications of CT substudies in two low-risk TAVR trials published earlier this year focusing hypo-attenuated leaflet thickening. 19,20 These highlighted the highly dynamic nature of HALT with 50% naturally disappearing between 30 days and 1 year, and 20% spontaneously appearing at 1 year despite a normal scan at 30 days. This continues to be a significant clinical conundrum as highlighted by the GALILEO 4D trial showing that routine use of anticoagulants better reduced the prevalence of HALT than antiplatelet agents, but also was associated with a higher risk of death, or thromboembolic complications, and a higher risk of bleeding than an antiplatelet-based strategy.…”

Section: Structural Heart Diseasementioning

confidence: 99%

Highlights of the 15th annual scientific meeting of the Society of Cardiovascular Computed Tomography

Weir‐McCall

Branch

Ferencik

et al. 2020

Journal of Cardiovascular Computed Tomography

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The 15th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting (ASM) welcomed 770 digital attendees from 44 countries, over 2 days, with a program that included 30 sessions across three simultaneously streaming channels, 10 exhibitors and a diverse range of scientific abstracts. In addition, #SCCT2020 generated >5900 tweets from nearly 700 engaged social media participants resulting in an estimated 38 million digital impressions and becoming #1 trending medical meeting in social media in the world during the meeting time period. This article summarizes the many themes and topics of presentation and discussion in this meeting, and the many technical advances that are likely to impact future clinical practice in cardiovascular computed tomography.

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“…HALT was found to have an incidence of approximately 10% at 30 days, increasing up to 24% at 1 year. 48 Interestingly, HALT minimally affects transvalvular gradients, does not cause clinical adverse events, and spontaneously resolves in half of cases without any need for OAC. 48 A recent meta-analysis of one RCT and 17 observational trials found that, whereas clinically apparent thrombosis is very rare (0.48% per year), subclinical leaflet thrombosis is common (16.32% per year).…”

Section: Leaflet Thrombosismentioning

confidence: 99%

“…48 Interestingly, HALT minimally affects transvalvular gradients, does not cause clinical adverse events, and spontaneously resolves in half of cases without any need for OAC. 48 A recent meta-analysis of one RCT and 17 observational trials found that, whereas clinically apparent thrombosis is very rare (0.48% per year), subclinical leaflet thrombosis is common (16.32% per year). 49 Importantly, leaflet thrombosis seems to lead to an increased risk of further thrombotic events, probably due to the distal embolisation of microthrombi; 49 unfortunately, current data are too sparse to draw a final conclusion.…”

Section: Leaflet Thrombosismentioning

confidence: 99%

Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status

Greco

Capodanno

2020

Interv Cardiol

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Transcatheter aortic valve implantation (TAVI) is the standard of care for symptomatic severe aortic stenosis. Antithrombotic therapy is required after TAVI to prevent thrombotic complications but it increases the risk of bleeding events. Current clinical guidelines are mostly driven by expert opinion and therefore yield low-grade recommendations. The optimal antithrombotic regimen following TAVI has yet to be determined and several randomised controlled trials assessing this issue are ongoing. The purpose of this article is to critically explore the impact of antithrombotic drugs, especially anticoagulants, on long-term clinical outcomes following successful TAVI.

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Subclinical Leaflet Thrombosis in Transcatheter and Surgical Bioprosthetic Valves

Cited by 180 publications

References 21 publications

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies

Highlights of the 15th annual scientific meeting of the Society of Cardiovascular Computed Tomography

Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status

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