Clinical Valve Thrombosis After Valve-in-Valve Transcatheter Aortic Valve Replacement
2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 11 Linguagem: Inglês
10.1161/circinterventions.118.007495
ISSN1941-7632
Autores Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculation: Cardiovascular InterventionsVol. 11, No. 11Clinical Valve Thrombosis After Valve-in-Valve Transcatheter Aortic Valve Replacement Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBClinical Valve Thrombosis After Valve-in-Valve Transcatheter Aortic Valve ReplacementAnother Bird of the Same Feather? Andrew Wang, MD Andrew WangAndrew Wang Andrew Wang, MD, Duke University Medical Center, DUMC 3428, Durham, NC 27710. Email E-mail Address: [email protected] Duke University Medical Center, Durham, NC. Originally published16 Nov 2018https://doi.org/10.1161/CIRCINTERVENTIONS.118.007495Circulation: Cardiovascular Interventions. 2018;11:e007495This article is a commentary on the followingClinical Valve Thrombosis After Transcatheter Aortic Valve-in-Valve ImplantationSee Article by Abdel-Wahab et alBioprosthetic valve thrombosis (BPVT) has rapidly become a well-recognized complication of both surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) prostheses.1 Although the incidence of BPVT is reported to be 10% to 15%, the methods and criteria for the spectrum of BPVT diagnosis have been variable. This variability in imaging modalities, protocol (ie, consecutive versus selected patients) and timing of imaging, and diagnostic criteria impacts current understanding of the natural history and appropriate management of BPVT when identified.Imaging findings of BPVT include hypoattenuating leaflet thickening, hypoattenuation affecting motion, and increased prosthetic valve gradient (>50% increase from baseline gradient by Doppler echocardiography).2 However, the relationships between imaging evidence of thrombus formation, adverse hemodynamic effects on the bioprosthetic valve function, and clinical sequelae (heart failure symptoms, neurological events, or prosthetic valve degeneration) are not clearly delineated. In a recent study of 84 patients who had either TAVR or SAVR and evidence of hypoattenuating leaflet thickening or hypoattenuation affecting motion within 1 year of valve implantation, a similar percentage of patients had evidence of progression or regression of subclinical, radiographically identified thrombus without change in anticoagulation therapy.3In this issue of Circulation: Cardiovascular Interventions, Abdel-Wahab et al4 describe the incidence, timing, risk factors, and presentation of clinical BPVT after Valve-in-Valve (ViV) TAVR. The study included 300 ViV TAVR cases, a subgroup of the Valve-in-Valve International Data registry that involved 7 centers. The majority of SAVR prostheses were stented, and there was a similar percentage of balloon-expandable and self-expandable TAVR devices used for the ViV procedures. Among 23 cases of clinical BPVT, 2 of 3 patients presented with symptoms, and 91% had increased transvalvular pressure gradients. At a median time of diagnosis of 101 days, the incidence of clinical BPVT was 7.6%, higher than the reported rate of clinical BPVT after native valve TAVR.5 Risk factors associated with BPVT included the lack of oral anticoagulant therapy, diameter of SAVR relative to body surface area, and type of SAVR prosthesis. Although most patients were symptomatic, BPVT was not associated with any deaths or strokes. Oral anticoagulation (either vitamin K antagonist or direct oral anticoagulant) was used in all cases of BPVT and was associated with reduced transvalvular pressure gradient across the ViV, similar to previous reports after TAVR and SAVR.6The results contribute to our growing understanding of BPVT, specifically related to the increasingly common use of TAVR for ViV procedures. A strength of this study is its multicenter design involving experienced and knowledgeable investigators and centers in the field. In addition, the study has identified characteristics of ViV procedures that were associated with a significantly increased risk of clinical BPVT; these factors may help to identify a subset of patients undergoing ViV that should be observed more closely, including echocardiographic assessment of the transvalvular gradient.There are limitations in this study that raise questions for future studies of BPVT after ViV TAVR. The incidence of BPVT is biased not only by the case definition based on clinical presentation, but also by this nonconsecutive subgroup of ViV cases in the registry (as previous reports from this cohort have included 1612 patients from 165 centers).7 Similarly, the reported timing of BPVT is based on clinical recognition, rather than routine surveillance with scheduled imaging intervals to identify subclinical hypoattenuating leaflet thickening or hypoattenuation affecting motion and their changes over time. However, detection of hypoattenuating leaflet thickening and hypoattenuation affecting motion may be less sensitive in ViV BPVT because of reduced visualization in the presence of increased prosthetic material, particularly with stented prosthetic valves.Although important clinical risk factors have been suggested, other factors that have been related to BPVT, such as atrial fibrillation,8 were not reported. Along these lines, it is interesting to note that the patients who developed BPVT had a higher rate of previous and post-TAVR strokes, but lower rate of oral anticoagulant use before and after ViV TAVR. Evaluation the computed tomography findings of the surgical valve prostheses before TAVR may identify findings associated with BPVT. Previous studies of BPVT after SAVR have identified a higher rate of BPVT with porcine prostheses,9 perhaps related to the attachment of the base of the leaflets to the stent frame (rail).10 The association between porcine SAVR and BPVT after ViV TAVR raises the question of preexisting thrombus may promote ongoing thrombosis.Aside from the possible benefit of oral anticoagulation for the prevention and treatment of BPVT after ViV TAVR are there other procedural considerations that may reduce the risk of this clinical complication? The present study again offers hypotheses for future testing. Given the incidence of severe patient-prosthetic mismatch and the association between BPVT and SAVR diameter to body surface area, could fracturing of the SAVR stent frame before or after TAVR implantation reduce patient-prosthetic mismatch and the incidence of BPVT,11 perhaps by improving TAVR leaflet mobility and neosinus blood flow? Also, does the choice of TAVR device influence the incidence of BPVT after ViV implantation? Although there was no association between type of TAVR and BPVT in the current study, another study has reported an association between balloon-expandable TAVR and thrombosis,5 as the supra-annular leaflets in self-expandable TAVR devices may be associated with less stagnant blood flow in the neosinus.12 As the use of TAVR for structural SAVR deterioration continues to grow, there may be unique aspects of ViV procedures that will differentiate BPVT diagnosis, prevention and treatment from TAVR or SAVR for native aortic valve stenosis.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circinterventionsAndrew Wang, MD, Duke University Medical Center, DUMC 3428, Durham, NC 27710. Email a.[email protected]eduReferences1. 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Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study.Lancet. 2017; 389:2383–2392. doi: 10.1016/S0140-6736(17)30757-2CrossrefMedlineGoogle Scholar7. Ribeiro HB, Rodés-Cabau J, Blanke P, Leipsic J, Kwan Park J, Bapat V, Makkar R, Simonato M, Barbanti M, Schofer J, Bleiziffer S, Latib A, Hildick-Smith D, Presbitero P, Windecker S, Napodano M, Cerillo AG, Abdel-Wahab M, Tchetche D, Fiorina C, Sinning JM, Cohen MG, Guerrero ME, Whisenant B, Nietlispach F, Palma JH, Nombela-Franco L, de Weger A, Kass M, Sandoli de Brito F, Lemos PA, Kornowski R, Webb J, Dvir D. Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry.Eur Heart J. 2018; 39:687–695. doi: 10.1093/eurheartj/ehx455CrossrefMedlineGoogle Scholar8. Ruile P, Minners J, Breitbart P, Schoechlin S, Gick M, Pache G, Neumann FJ, Hein M. Medium-term follow-up of early leaflet thrombosis after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11:1164–1171. doi: 10.1016/j.jcin.2018.04.006CrossrefMedlineGoogle Scholar9. Jander N, Sommer H, Pingpoh C, Kienzle RP, Martin G, Zeh W, Pache G, Siepe M, Beyersdorf F, Schumacher M, Neumann FJ, Minners J. The porcine valve type predicts obstructive thrombosis beyond the first three postoperative months in bioprostheses in the aortic position.Int J Cardiol. 2015; 199:90–95. doi: 10.1016/j.ijcard.2015.07.022CrossrefMedlineGoogle Scholar10. Brown ML, Park SJ, Sundt TM, Schaff HV. Early thrombosis risk in patients with biologic valves in the aortic position.J Thorac Cardiovasc Surg. 2012; 144:108–111. doi: 10.1016/j.jtcvs.2011.05.032CrossrefMedlineGoogle Scholar11. Chhatriwalla AK, Allen KB, Saxon JT, Cohen DJ, Aggarwal S, Hart AJ, Baron SJ, Dvir D, Borkon AM. Bioprosthetic valve fracture improves the hemodynamic results of valve-in-valve transcatheter aortic valve replacement.Circ Cardiovasc Interv. 2017; 10:e005216. doi: 10.1161/CIRCINTERVENTIONS.117.005216LinkGoogle Scholar12. Midha PA, Raghav V, Sharma R, Condado JF, Okafor IU, Rami T, Kumar G, Thourani VH, Jilaihawi H, Babaliaros V, Makkar RR, Yoganathan AP. The fluid mechanics of transcatheter heart valve leaflet thrombosis in the neosinus.Circulation. 2017; 136:1598–1609. doi: 10.1161/CIRCULATIONAHA.117.029479LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesClinical Valve Thrombosis After Transcatheter Aortic Valve-in-Valve ImplantationMohamed Abdel-Wahab, et al. Circulation: Cardiovascular Interventions. 2018;11 November 2018Vol 11, Issue 11 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.118.007495PMID: 30571217 Originally publishedNovember 16, 2018 Keywordsheart failuretranscatheter aortic value replacementaortic valvethrombosisEditorialshemodynamicsPDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve Implantation
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