Treatment and Clinical Outcomes of Transcatheter Heart Valve Thrombosis

Abstract

Background— Valve thrombosis has yet to be fully evaluated after transcatheter aortic valve implantation. This study aimed to report the prevalence, timing, and treatment of transcatheter heart valve (THV) thrombosis. Methods and Results— THV thrombosis was defined as follows (1) THV dysfunction secondary to thrombosis diagnosed based on response to anticoagulation therapy, imaging modality or histopathology findings, or (2) mobile mass detected on THV suspicious of thrombus, irrespective of dysfunction and in absence of infection. Between January 2008 and September 2013, 26 (0.61%) THV thromboses were reported out of 4266 patients undergoing transcatheter aortic valve implantation in 12 centers. Of the 26 cases detected, 20 were detected in the Edwards Sapien/Sapien XT cohort and 6 in the Medtronic CoreValve cohort. In patients diagnosed with THV thrombosis, the median time to THV thrombosis post–transcatheter aortic valve implantation was 181 days (interquartile range, 45–313). The most common clinical presentation was exertional dyspnea (n=17; 65%), whereas 8 (31%) patients had no worsening symptoms. Echocardiographic findings included a markedly elevated mean aortic valve pressure gradient (40.5±14.0 mm Hg), presence of thickened leaflets or thrombotic apposition of leaflets in 20 (77%) and a thrombotic mass on the leaflets in the remaining 6 (23%) patients. In 23 (88%) patients, anticoagulation resulted in a significant decrease of the aortic valve pressure gradient within 2 months. Conclusions— THV thrombosis is a rare phenomenon that was detected within the first 2 years after transcatheter aortic valve implantation and usually presented with dyspnea and increased gradients. Anticoagulation seems to have been effective and should be considered even in patients without visible thrombus on echocardiography.

Comparison of dual antiplatelet therapy versus oral anticoagulation following transcatheter aortic valve replacement: A retrospective single-center registry analysis

“…In the relatively young era of percutaneous aortic valve replacement, an increasing number of reports has emerged describing cases of clinically relevant subacute post-TAVR valve thrombosis and recently identified reduced leaflet motion in MDCT, which may correspond to a subclinical surrogate of valve thrombosis [10,11,[23][24][25]. These reports about post-TAVR valve thrombosis and hindered leaflet function have generated debate about the clinical relevance of this phenomenon.…”

“…Identifying the appropriate anticoagulation strategy after TAVR remains an important clinical challenge that has resulted in a large variability of antithrombotic therapies, ranging from triple therapy (DAPT + oral anticoagulation [OAC]) to vitamin-K antagonists (VKA) alone [9]. Finally, recent reports on low but clinically relevant incidence of valve thrombosis hindering prosthesis function may further lead to an upheaval in the landscape of thrombotic therapy after TAVR [10][11][12].…”

Hot Topics in Transcatheter Aortic Valve Implantation

“…Latib et al first reported the frequency, clinical presentation and management of THV thrombosis from a multicenter registry [13]. The overall incidence of symptomatic THV thrombosis was 0.6%.…”

“…THV thrombosis presented as thickened leaflets or thrombotic apposition of leaflets in 76.9% and thrombotic mass on the leaflets in 23.1%. 23 out of 26 patients (88.4%) were successfully treated with anticoagulation; two patients underwent a transcatheter valve-in-valve procedure and one patient underwent surgical aortic valve replacement [13]. More recently, hypoattenuated leaflet thickening (HALT) and reduced leaflet motion (RELM) of bioprosthetic aortic valves associated with normal transvalvular gradients (possibly related to subclinical leaflet thrombosis) have been reported as affecting both transcatheter and surgical aortic valves.…”

Thrombosis of TAVI prosthesis—cause for concern or innocent bystander? A comment and review of currently available data

“…The largest cohort of patients with transcatheter heart valve (THV) changes was published by the Milan group, who presented multicenter data on 4266 patients undergoing TAVI [19]. The authors defined THV dysfunction as a mean gradient of 20 mmHg on echocardiography, and THV thrombosis when according changes visualized in echo, CT, or histopathology.…”