Thrombotic Aortic Restenosis After Transapical Sapien Valve Implantation
2010; Lippincott Williams & Wilkins; Volume: 3; Issue: 3 Linguagem: Inglês
10.1161/circinterventions.109.935031
ISSN1941-7632
AutoresJoëlle Kefer, Parla Astarci, Jean Renkin, David Glineur, Sophie Piérard, Stéphanie Seldrum, Jean‐Louis Vanoverschelde,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculation: Cardiovascular InterventionsVol. 3, No. 3Thrombotic Aortic Restenosis After Transapical Sapien Valve Implantation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBThrombotic Aortic Restenosis After Transapical Sapien Valve Implantation Joelle Kefer, MD, PhD, Parla Astarci, MD, Jean Renkin, MD, PhD, David Glineur, MD, Sophie Pierard, MD, Stephanie Seldrum, MD and Jean-Louis Vanoverschelde, MD, PhD Joelle KeferJoelle Kefer From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. , Parla AstarciParla Astarci From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. , Jean RenkinJean Renkin From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. , David GlineurDavid Glineur From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. , Sophie PierardSophie Pierard From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. , Stephanie SeldrumStephanie Seldrum From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. and Jean-Louis VanoverscheldeJean-Louis Vanoverschelde From the Division of Cardiology (J.K., J.R., S.P., S.S., J.-L.V.) and Cardiovascular Surgery (P.A., D.G.), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. Originally published1 Jun 2010https://doi.org/10.1161/CIRCINTERVENTIONS.109.935031Circulation: Cardiovascular Interventions. 2010;3:289–292A 78-year-old man at high risk for aortic valve replacement (Euroscore, 44%; left ventricular ejection fraction, 30%; previous bypass graft surgery) had undergone a transapical aortic valve implantation (26-mm Edwards Sapien) with a good immediate clinical and echocardiographic outcome: peak transvalvular gradient, 15 mm Hg; aortic valve area, 1.6 cm2; and trivial aortic regurgitation (Figure 1). He was treated with dual-antiplatelet therapy (clopidogrel, 75 mg/d for 1 month; aspirin, 100 mg/d lifelong), as recommended after Sapien valve implantation. The clinical and echocardiographic follow-ups at 1 month were excellent (New York Heart Association class II; peak transvalvular gradient, 18 mm Hg; aortic valve area, 1.6 cm2).Download figureDownload PowerPointFigure 1. Transoesophageal echocardiography images immediately after implantation of the Sapien valve. A, Low aortic transvalvular gradient; B, thin and normal leaflets; C, trivial aortic regurgitation.The patient was admitted 4 months after the procedure to the emergency department with a non–ST segment elevation myocardial infarction, signs of left heart failure, and an aortic systolic murmur. There was no evidence of endocarditis: no fever, no rash, and normal inflammatory parameters as per laboratory findings.The coronary angiogram showed graft patency, and the aortic angiogram (Figure 2) demonstrated an asymmetrical opening of the Sapien valve leaflets, despite the circular shape and transannular position of the stent, and the absence of a significant aortic regurgitation (supplemental movie in the online-only Data Supplement). During cardiac catheterization, a ViewFlex catheter (St. Jude Medical) was introduced through the femoral vein to perform intracardiac echocardiography, which showed a thickened aspect of the Sapien valve and thrombus on the leaflets, resulting in a significant aortic transvalvular gradient (Figure 3). These intracardiac echocardiographic findings were comparable with those of the transesophageal assessment (Figure 4): thickening of the leaflets, peak transvalvular gradient of 73 mm Hg, aortic valve area reduced to 0.4 cm2, and trivial aortic regurgitation.Download figureDownload PowerPointFigure 2. Asymmetrical opening of the Sapien valve leaflets on the aortic angiogram. During the systolic phase, the opening movement of the posterior leaflet (dashed arrow) is significantly higher than that of the leaflet on the opposite side (solid arrow).Download figureDownload PowerPointFigure 3. Intracardiac echocardiogram shows the struts of the Sapien valve stent (solid arrows) and the thrombus on the prosthesis leaflets (dashed arrows). Intracardiac echocardiography Doppler measured a transvalvular aortic velocity close to 4 m/s.Download figureDownload PowerPointFigure 4. Transoesophageal echocardiography shows thickened leaflets (long-axis view [A] and short-axis view [B]) and severe stenosis of the Sapien valve (high transvalvular gradient [C]).Screening tests for thrombophilia (including abnormalities of protein C, protein S, antithrombin III, homocysteine plasma level, factor V Leiden mutation, prothrombin G20210A gene mutation, and antiphospholipid antibodies) were performed, showing the absence of any coagulation disorder and a normal response to aspirin (ristocetin- and 2 μg/mL ADP–induced platelet aggregation reduced at 24% and 39%, respectively).Because there was a clinical suspicion of an aortic bioprosthetic thrombosis, the patient received heparin followed by Coumadin therapy. After 1 month of anticoagulant therapy, the peak transvalvular gradient significantly decreased to 22 mm Hg, the aortic valve area increased to 1.2 cm2, and the Sapien valve leaflets appeared more mobile and thinner (Figure 5).Download figureDownload PowerPointFigure 5. Echocardiography images after 1 month of anticoagulant therapy shows thinner leaflets of the Sapien valve (long-axis view [A] and short-axis view [B]) and a reduction of transvalvular gradient (C).DiscussionThis case shows that bioprosthetic thrombosis after a successful transcatheter aortic valve implantation can occur even in the absence of a coagulation disorder or stopping antiplatelet therapy. As published by Cribier et al,1 antiplatelet therapy after transfemoral aortic valve implantation in the I-REVIVE and RECAST trials is clopidogrel 75 mg/d for 1 month and low-dose aspirin indefinitely. After Sapien valve implantation, the aortic endothelium is in contact with a stainless steel stent, and it seems logical to apply the same rules that are used after bare-metal stent implantation in coronary arteries.2 Recommendations after CoreValve ReValving system implantation are a prolonged dual-antiplatelet therapy: clopidogrel for 6 months and aspirin lifelong. The asymmetrical geometry and the incomplete apposition of the nitinol stent3 may predispose to a higher risk of thrombosis and leaflet distortion, compared with the short and circular stent of the Sapien valve.The leaflets of the Sapien valve are bovine pericardium treated similarly to the surgical bioprosthesis, for which anticoagulation by warfarin is recommended during the first 3 months.4 The risk of thromboemboli after open-heart surgery is probably higher than after transcatheter aortic valve implantation. The transapical approach requires chest and a small heart opening as opposed to the transfemoral technique. This case suggests that preventive antithrombotic measures after transcatheter Sapien valve implantation could be different between the transapical and transfemoral approach.The aortic bioprosthesis dysfunction was detected by using transesophageal echocardiography; the good clinical and echocardiographic outcome while the patient was receiving anticoagulant therapy suggested the thrombotic aortic restenosis, which was not confirmed by histology or by visual inspection because open-heart surgery was not needed. Moreover, we evaluated the ability of intracardiac echocardiography to detect a late aortic Sapien valve dysfunction and to explain its origin. Intracardiac echocardiography is an attractive technique to assist the procedure of transcatheter aortic valve implantation because it can be done without requiring general anesthesia and the catheter can be left in place in the right atrium without interfering with the view of the native aortic valve. In addition, this case suggests that intracardiac echocardiography is an accurate imaging technique to detect and explain the reason for a late aortic bioprosthesis dysfunction.ConclusionThrombotic aortic restenosis after transcatheter aortic valve replacement with the Sapien valve is an uncommon situation, not yet well described, which can be successfully treated by anticoagulant therapy. Intracardiac echocardiography, an accurate technique to assist the procedure of transcatheter aortic valve implantation, could also be instrumental in diagnosing late aortic bioprosthesis dysfunction.DisclosuresNone.FootnotesThe online Data Supplement is available at http://circinterventions.ahajournals.org/cgi/content/full/3/3/289/DC1.Correspondence to Joelle Kefer, MD, PhD, Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Ave Hippocrate, 10-2881, 1200 Brussels, Belgium. E-mail joelle.[email protected]beReferences1. Cribier A, Eltchaninoff H, Tron C, Bauer B, Agatiello C, Nercolini D, Tapiero S, Litzler PY, Bessou JP, Babaliaros V. Treatment of calcific aortic stenosis with the percutaneous heart valve. J Am Coll Cardiol. 2006; 47:1214–1223.CrossrefMedlineGoogle Scholar2. King S, Smith S, Hirshfeld J, Jacobs A, Morrisson D, William D, Feldman T, Kern M, O'Neil W, Scaff H, Whitlow P, Adams C, Anderson J, Buller C, Creager M, Ettinger S, Halperin J, Hunt S, Krumholz H, Kushner F, Lytle B, Nischimura R, Page R, Riegel B, Tarkington L, Yancy C. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention. Circulation. 2008; 117:261–295.LinkGoogle Scholar3. Schultz C, Weustink A, Piazza N, Otten A, Mollet N, Krestin G, van Geuns RJ, de Feyter P, Serruys P, de Jaegere P. Geometry and degree of apposition of the CoreValve ReValving system with multislice computed tomography after implantation in patients with aortic stenosis. J Am Coll Cardiol. 2009; 54:911–918.CrossrefMedlineGoogle Scholar4. Bonow R, Carabello B, Chatterjee K, de Leon A, Faxon D, Freed M, Gaasch W, Lytle BW, Nishimura R, O'Gara P, O'Rourke R, Otto C, Shah P, Shanewise J. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006; 114:e84–e231.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByGuedeney P, Mehran R, Collet J, Claessen B, ten Berg J and Dangas G (2019) Antithrombotic Therapy After Transcatheter Aortic Valve Replacement, Circulation: Cardiovascular Interventions, 12:1, Online publication date: 1-Jan-2019. Goleski P, Reisman M and Don C (2016) Reversible thrombotic aortic valve restenosis after valve-in-valve transcatheter aortic valve replacement, Catheterization and Cardiovascular Interventions, 10.1002/ccd.26522, 91:1, (165-168), Online publication date: 1-Jan-2018. Soon J, Pibarot P, Blanke P, Ohana M and Leipsic J (2017) Multimodality Imaging for Planning and Follow-up of Transcatheter Aortic Valve Replacement, Canadian Journal of Cardiology, 10.1016/j.cjca.2017.03.024, 33:9, (1110-1123), Online publication date: 1-Sep-2017. Chakravarty T, Abramowitz Y, Jilaihawi H and Makkar R (2016) Leaflet motion abnormality after TAVI: genuine threat or much ado about nothing?, EuroIntervention, 10.4244/EIJV12SYA7, 12:Y, (Y28-Y32), Online publication date: 1-Sep-2016. Hamm C, Arsalan M and Mack M (2015) The future of transcatheter aortic valve implantation, European Heart Journal, 10.1093/eurheartj/ehv574, 37:10, (803-810), Online publication date: 7-Mar-2016. Gonska B, Seeger J, Rodewald C, Scharnbeck D, Rottbauer W and Wöhrle J (2016) Transfemoral valve-in-valve implantation for degenerated bioprosthetic aortic valves using the new balloon-expandable Edwards Sapien 3 valve, Catheterization and Cardiovascular Interventions, 10.1002/ccd.26565, 88:4, (636-643), Online publication date: 1-Oct-2016. Leetmaa T, Hansson N, Leipsic J, Jensen K, Poulsen S, Andersen H, Jensen J, Webb J, Blanke P, Tang M and Nørgaard B (2015) Early Aortic Transcatheter Heart Valve Thrombosis, Circulation: Cardiovascular Interventions, 8:4, Online publication date: 1-Apr-2015.Latib A, Naganuma T, Abdel-Wahab M, Danenberg H, Cota L, Barbanti M, Baumgartner H, Finkelstein A, Legrand V, de Lezo J, Kefer J, Messika-Zeitoun D, Richardt G, Stabile E, Kaleschke G, Vahanian A, Laborde J, Leon M, Webb J, Panoulas V, Maisano F, Alfieri O and Colombo A (2015) Treatment and Clinical Outcomes of Transcatheter Heart Valve Thrombosis, Circulation: Cardiovascular Interventions, 8:4, Online publication date: 1-Apr-2015. Córdoba-Soriano J, Puri R, Amat-Santos I, Ribeiro H, Abdul-Jawad Altisent O, del Trigo M, Paradis J, Dumont E, Urena M and Rodés-Cabau J (2015) Valve Thrombosis Following Transcatheter Aortic Valve Implantation: A Systematic Review, Revista Española de Cardiología (English Edition), 10.1016/j.rec.2014.10.003, 68:3, (198-204), Online publication date: 1-Mar-2015. Córdoba-Soriano J, Puri R, Amat-Santos I, Ribeiro H, Abdul-Jawad Altisent O, del Trigo M, Paradis J, Dumont E, Urena M and Rodés-Cabau J (2015) Revisión sistemática de la trombosis protésica tras implante percutáneo de válvula aórtica, Revista Española de Cardiología, 10.1016/j.recesp.2014.10.004, 68:3, (198-204), Online publication date: 1-Mar-2015. De Marchena E, Mesa J, Pomenti S, Marin y Kall C, Marincic X, Yahagi K, Ladich E, Kutys R, Aga Y, Ragosta M, Chawla A, Ring M and Virmani R (2015) Thrombus Formation Following Transcatheter Aortic Valve Replacement, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2015.03.005, 8:5, (728-739), Online publication date: 1-Apr-2015. Mylotte D, Andalib A, Theriault-Lauzier P, Dorfmeister M, Girgis M, Alharbi W, Chetrit M, Galatas C, Mamane S, Sebag I, Buithieu J, Bilodeau L, de Varennes B, Lachapelle K, Lange R, Martucci G, Virmani R and Piazza N (2014) Transcatheter heart valve failure: a systematic review, European Heart Journal, 10.1093/eurheartj/ehu388, 36:21, (1306-1327), Online publication date: 1-Jun-2015. Nijenhuis V, Bennaghmouch N, Kuijk J, Capodanno D and ten Berg J (2017) Antithrombotic treatment in patients undergoing transcatheter aortic valve implantation (TAVI), Thrombosis and Haemostasis, 10.1160/TH14-10-0821, 113:04, (674-685), Online publication date: 1-Jul-2015. Descoux J, Gautier-Pignonblanc P, Innorta A, Durel N, Camilleri L, Motreff P, Lusson J and Souteyrand G (2015) Effectiveness of anticoagulant therapy in the treatment of post-TAVI bioprosthetic thrombosis, Journal of Cardiothoracic Surgery, 10.1186/s13019-015-0254-5, 10:1, Online publication date: 1-Dec-2015. Pergolini A, Pino P, Zampi G, Polizzi V and Musumeci F (2013) Thrombotic Aortic Restenosis After Transapical SAPIEN Valve Implantation, Journal of Cardiac Surgery, 10.1111/jocs.12275, 29:2, (204-208), Online publication date: 1-Mar-2014. Iung B and Rodes-Cabau J (2014) The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties, European Heart Journal, 10.1093/eurheartj/ehu365, 35:42, (2942-2949), Online publication date: 2-Nov-2014. Piazza N, Mylotte D and Martucci G (2013) Transcatheter Aortic Valve Implantation Heart Valves, 10.1007/978-1-4614-6144-9_10, (227-260), . Mylotte D, Martucci G, Lange R and Piazza N (2013) Transfemoral transcatheter aortic valve replacement Endovascular and Hybrid Therapies for Structural Heart and Aortic Disease, 10.1002/9781118504536.ch14, (141-169) Latib A, Messika-Zeitoun D, Maisano F, Himbert D, Agricola E, Brochet E, Alfieri O, Colombo A and Vahanian A (2013) Reversible Edwards Sapien XT Dysfunction Due to Prosthesis Thrombosis Presenting as Early Structural Deterioration, Journal of the American College of Cardiology, 10.1016/j.jacc.2012.10.016, 61:7, (787-789), Online publication date: 1-Feb-2013. Hansson N, Tang M, Jensen J, Rasmussen V, Poulsen S and Nørgaard B (2013) Early transcatheter heart valve thrombosis detected by multidetector computed tomography, IJC Heart & Vessels, 10.1016/j.ijchv.2013.11.006, 2, (24-25), Online publication date: 1-Mar-2013. June 2010Vol 3, Issue 3 Advertisement Article InformationMetrics © 2010 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.109.935031PMID: 20551396 Manuscript receivedDecember 29, 2009Manuscript acceptedMarch 11, 2010Originally publishedJune 1, 2010 Keywordsthrombosisechocardiographyvalvuloplastytranscatheter aortic valve implantationaortic valvePDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsEchocardiographyImagingRestenosisValvular Heart Disease
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