Thrombotic Restenosis After Minimally Invasive Implantation of Aortic Valve Stent
2009; Lippincott Williams & Wilkins; Volume: 120; Issue: 4 Linguagem: Inglês
10.1161/circulationaha.109.864892
ISSN1524-4539
AutoresThomas Trepels, Sven Martens, Mirko Doss, Stephan Fichtlscherer, Volker Schächinger,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 120, No. 4Thrombotic Restenosis After Minimally Invasive Implantation of Aortic Valve Stent Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBThrombotic Restenosis After Minimally Invasive Implantation of Aortic Valve Stent Thomas Trepels, MD, Sven Martens, MD, Mirko Doss, MD, Stephan Fichtlscherer, MD and Volker Schächinger, MD Thomas TrepelsThomas Trepels From the Department of Internal Medicine III (T.T., S.F., V.S.), and Department of Thoracic and Cardiovascular Surgery (S.M., M.D.), J. W. Goethe University, Frankfurt, Germany. , Sven MartensSven Martens From the Department of Internal Medicine III (T.T., S.F., V.S.), and Department of Thoracic and Cardiovascular Surgery (S.M., M.D.), J. W. Goethe University, Frankfurt, Germany. , Mirko DossMirko Doss From the Department of Internal Medicine III (T.T., S.F., V.S.), and Department of Thoracic and Cardiovascular Surgery (S.M., M.D.), J. W. Goethe University, Frankfurt, Germany. , Stephan FichtlschererStephan Fichtlscherer From the Department of Internal Medicine III (T.T., S.F., V.S.), and Department of Thoracic and Cardiovascular Surgery (S.M., M.D.), J. W. Goethe University, Frankfurt, Germany. and Volker SchächingerVolker Schächinger From the Department of Internal Medicine III (T.T., S.F., V.S.), and Department of Thoracic and Cardiovascular Surgery (S.M., M.D.), J. W. Goethe University, Frankfurt, Germany. Originally published28 Jul 2009https://doi.org/10.1161/CIRCULATIONAHA.109.864892Circulation. 2009;120:e23–e24An 84-year-old woman underwent successful, minimally invasive, transapical aortic valve implantation (Edwards SAPIEN 23 mm) to address symptomatic high-grade aortic stenosis and logistic EuroScore of 22%. Echocardiographic control after 11 and 41 days demonstrated the valve in good position without relevant paravalvular leakage or aortic regurgitation. Mean gradients over aortic valve implant were 17 mm Hg and 19 mm Hg, respectively. At echocardiographic follow-up at 6 and 8 months, mean gradient increased to 40 mm Hg and 53 mm Hg, respectively. The patient also developed dyspnea on exertion again. Transesophageal echocardiography at 8 months demonstrated 1 well opening aortic valve leaflet at the septal side, whereas an echodense structure was visible at the opposite side (Figure 1 and online-only Data Supplement Movie I). Aortic angiogram was performed and demonstrated a large round contrast defect at the height of the aortic valve stent below the left coronary artery (Figure 2 and online-only Data Supplement Movie II). Download figureDownload PowerPointFigure 1. Transesophageal echocardiography (long axis) of aortic valve stent 8 months after implantation. Black arrows denote thrombus on valve stent. White arrows denote thrombus-free leaflet, which demonstrated good mobility.Download figureDownload PowerPointFigure 2. Aortic angiogram. White arrows denote thrombus formation within aortic valve stent.Thereafter, successful open-heart surgery was performed to replace the restenotic aortic valve stent by a conventional aortic valve bioprosthesis. At this time, large, organized thrombi on 2 of the leaflets, as cause of the valve restenosis, were detected (Figure 3). Histology revealed a thrombus formation with fibrous organization without evidence for an infectious endocarditis. Download figureDownload PowerPointFigure 3. Intraoperative view on aortic valve stent before replacement by conventional bioprosthesis. Large thrombi are visible on 2 of the 3 leaflets.Thrombotic restenosis after aortic valve surgery using bioprosthesis is very uncommon1 and has not yet been described after minimally invasive aortic valve stent implantation. Of note, leaflets of the Edwards SAPIEN aortic valve stent are processed in the same way as established for conventional aortic bioprosthesis, making it unlikely that thrombogenicity of leaflets is per se enhanced with this aortic valve stent.There are 3 possible reasons, or a combination of those, for development of thrombosis in this patient: First, the patient reported that she did not take aspirin and clopidogrel any more than beyond 6 weeks after valve implantation, despite oral and written recommendations. Clopidogrel is recommended for 6 months and aspirin lifelong after Edwards SAPIEN valve implantation.Second, a coagulation disorder may predispose for thrombus formation on aortic valve stent leaflets. Subsequently, screening tests for thrombophilia were performed, which excluded common disorders, including antiphospholipid antibodies and abnormalities in protein C, antithrombin III, and genetic analysis of factor V and II. However, mild reduction of protein S activity (50%) and positive cold agglutinins were detected.Third, another possibility is geometric deformation of the aortic valve stent, which may predispose for thrombus formation as a result of flow turbulences.2 Using Cribier-Edwards/SAPIEN aortic valve stents, it is recommended to oversize valve diameter compared with aortic annulus in order to minimize aortic regurgitation due to paravalvular leakage.3 Likewise, in this patient, a 23-mm valve was implanted into an 18-mm annulus (diameter measured by transesophageal echocardiography). However, no relevant aortic regurgitation was detected by transesophageal echocardiography immediately after valve stent implantation, excluding maladaptation of the leaflets due to gross geometric distortion of the valve.The online-only Data Supplement can be found at http://circ.ahajournals.org/cgi/content/full/120/4/e23/DC1.DisclosuresDr Doss has received support as Proctor (Edwards Lifesciences). Dr Schächinger reports research support (<$10k) for the Partner–Trial from Edwards Lifescience. The remaining authors report no conflicts.FootnotesCorrespondence to Dr Volker Schächinger, Director, Clinic of Internal Medicine I, (Cardiology, Angiology, Pneumology), Pacelliallee 4, D- 36043 Fulda, Germany. E-mail [email protected]References1 Laksman Z, Kane GC, Murphy JG. Thrombolytic therapy for late thrombosis of a bioprosthetic mitral valve: atypical diagnostic echocardiographic features and a review of the literature. J Heart Valve Dis. 2008; 17: 670–673.MedlineGoogle Scholar2 Piazza N, de Jaegere P, Becker A, Serruys P, Anderson R. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Intervent. 2008; 1: 74–81.LinkGoogle Scholar3 Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, Sinhal A, Carere RG, Munt B, Ricci D, Ye J, Cheung A, Lichtenstein SV. 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Li D, Ma X, Zhou X and Qian Y (2022) Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis, Frontiers in Pharmacology, 10.3389/fphar.2022.755009, 13 July 28, 2009Vol 120, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.864892PMID: 19635975 Originally publishedJuly 28, 2009 PDF download Advertisement SubjectsCardiovascular SurgeryCatheter-Based Coronary and Valvular InterventionsValvular Heart Disease
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