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Heart, Lung and Circulation

Early Bioprosthetic Valve Dysfunction Following TAVR: The Role of CT Imaging in Diagnosing Acute Leaflet Thrombosis1

      A 79-year-old female with severe aortic stenosis and hypertension was referred for transcatheter aortic valve replacement (TAVR). Computed tomography (CT) was performed for prosthesis sizing and ilio-femoral assessment (Figure 1A). She received aspirin and clopidogrel prior to TAVR. The patient received intra-arterial heparin (100 IU/kg) to achieve an activated clotting time above 250 seconds. A 23 mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA USA) was implanted (Figure 1B) and aortogram revealed no regurgitation.
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      Figure 1Pre-procedural computed tomography (CT) imaging (Image A) for prosthesis sizing revealed an annulus area of 340 mm2 and area-derived diameter of 21 mm. A 23 mm Sapien 3 valve was implanted and the procedure was well tolerated (Image B). On Day 1, the patient had residual significant transvalvular gradient with a peak velocity of 3.9 m/s and mean gradient of 36 mmHg (Image C). The leaflet was not visualised with transthoracic echocardiography, highlighted a limitation with this imaging modality to diagnose leaflet thrombosis (LT) (Image D). Post-procedural CT imaging revealed hypo-attenuated leaflet thickening (green arrowhead) of a single leaflet in both short-axis (Image E) and long-axis views (Image F). The prosthesis appeared under-expanded at the annular level (Images B and F, white asterisk). Four-dimensional (4D) volume rendering revealed significant restriction of leaflet mobility with a large thrombus burden (Images G & H) (blue arrowhead).

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      References

        • Khav N.
        • Rashid H.N.
        • Brown A.J.
        The role of four-dimensional computed tomography in transcatheter aortic valve replacement prosthesis endocarditis with concurrent leaflet thrombosis: a case report.
        Eur Heart J Case Rep. 2020; 4: 1-5
        • Makkar R.R.
        • Blanke P.
        • Leipsic J.
        • Thourani V.
        • Chakravarty T.
        • Brown D.
        • et al.
        Subclinical leaflet thrombosis in transcatheter and surgical bioprosthetic valves: PARTNER 3 cardiac computed tomography substudy.
        J Am Coll Cardiol. 2020; 75: 3003-3015
        • Rashid H.N.
        • Gooley R.P.
        • Nerlekar N.
        • Ihdayhid A.R.
        • McCormick L.M.
        • Nasis A.
        • et al.
        Bioprosthetic aortic valve leaflet thrombosis detected by multidetector computed tomography is associated with adverse cerebrovascular events: a meta-analysis of observational studies.
        EuroIntervention. 2018; 13: e1748-e1755
        • Bogyi M.
        • Schernthaner R.E.
        • Loewe C.
        • Gager G.M.
        • Dizdarevic A.M.
        • Kronberger C.
        • et al.
        Subclinical leaflet thrombosis after transcatheter aortic valve replacement: a meta-analysis.
        JACC Cardiovasc Interv. 2021; 14: 2643-2656
        • Rashid H.N.
        • Michail M.
        • Ramnarain J.
        • Nasis A.
        • Nicholls S.J.
        • Cameron J.D.
        • et al.
        The impact of hypo-attenuated leaflet thickening on haemodynamic valve deterioration following transcatheter aortic valve replacement.
        J Cardiovasc Comput Tomogr. 2022; 16: 168-173
        • Rashid H.N.
        • Michail M.
        • Ihdayhid A.R.
        • Dowling C.
        • Khav N.
        • Tan S.
        • et al.
        Clinical predictors and sequelae of computed tomography defined leaflet thrombosis following transcatheter aortic valve replacement at medium-term follow-up.
        Heart Vessels. 2021; 36: 1374-1383
        • Rashid H.N.
        • Gooley R.P.
        • Cameron J.D.
        Prosthesis geometrical factors in the development of hypo-attenuated leaflet thickening.
        J Am Coll Cardiol. 2020; 76: 1913-1914
        • Rashid H.N.
        • Nasis A.
        • Gooley R.P.
        • Cameron J.D.
        • Brown A.J.
        The prevalence of computed tomography-defined leaflet thrombosis in intra- versus supra-annular transcatheter aortic valve prostheses.
        Catheter Cardiovasc Interv. 2018; 92: 1414-1416
        • Midha P.A.
        • Raghav V.
        • Sharma R.
        • Condado J.F.
        • Okafor I.U.
        • Rami T.
        • et al.
        The fluid mechanics of transcatheter heart valve leaflet thrombosis in the neosinus.
        Circulation. 2017; 136: 1598-1609
        • Varc-3 Writing C.
        • Genereux P.
        • Piazza N.
        • Alu M.C.
        • Nazif T.
        • Hahn R.T.
        • et al.
        Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research.
        Eur Heart J. 2021; 42: 1825-1857
        • Dvir D.
        • Bourguignon T.
        • Otto C.M.
        • Hahn R.T.
        • Rosenhek R.
        • Webb J.G.
        • et al.
        Standardized definition of structural valve degeneration for surgical and transcatheter bioprosthetic aortic valves.
        Circulation. 2018; 137: 388-399
        • Dangas G.D.
        • Tijssen J.G.P.
        • Wohrle J.
        • Sondergaard L.
        • Gilard M.
        • Mollmann H.
        • et al.
        A controlled trial of rivaroxaban after transcatheter aortic-valve replacement.
        N Engl J Med. 2019; 382: 120-129
        • De Backer O.
        • Dangas G.D.
        • Jilaihawi H.
        • Leipsic J.A.
        • Terkelsen C.J.
        • Makkar R.
        • et al.
        Reduced leaflet motion after transcatheter aortic-valve replacement.
        N Engl J Med. 2020; 382: 130-139
        • Nijenhuis V.J.
        • Brouwer J.
        • Delewi R.
        • Hermanides R.S.
        • Holvoet W.
        • Dubois C.L.F.
        • et al.
        Anticoagulation with or without clopidogrel after transcatheter aortic-valve implantation.
        N Engl J Med. 2020; 382: 1696-1707
        • Brouwer J.
        • Nijenhuis V.J.
        • Delewi R.
        • Hermanides R.S.
        • Holvoet W.
        • Dubois C.L.F.
        • et al.
        Aspirin with or without clopidogrel after transcatheter aortic-valve implantation.
        N Engl J Med. 2020; 383: 1447-1457