Publish in this journal
Journal Information
Vol. 70. Issue 6.
Pages 512-514 (June 2017)
Share
Share
Download PDF
More article options
Vol. 70. Issue 6.
Pages 512-514 (June 2017)
Scientific letter
DOI: 10.1016/j.rec.2016.08.007
Full text access
“Subclinical” Leaflet Thrombosis in Transcatheter Aortic Valve Implantation: A Latent Risk?
Trombosis valvular “subclínica” tras implante percutáneo de válvula aórtica: ¿un riesgo latente?
Visits
...
Sergio Morala,
Corresponding author
moral.sergio@yahoo.es

Corresponding author:
, Juli Carballoa, Esther Ballesterosb, Alejandro Panaroa, Arturo Evangelistaa,c
a Departamento de Cardiología, Centro Cardiovascular Sant Jordi, Hospital del Pilar, Barcelona, Spain
b Departamento de Radiología, Centro de Atención Primaria Pare Claret, Instituto Catalán de la Salud, Barcelona, Spain
c Departamento de Cardiología, Hospital Universitario Vall d’Hebron, Barcelona, Spain
This item has received
...
Visits
(Daily data update)
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Additional material (3)
Full Text
To the Editor,

An 87-year-old man with symptomatic severe aortic valve stenosis and a previous percutaneous coronary intervention in the right coronary artery underwent transcatheter aortic valve implantation (TAVI) with a balloon-expandable prosthesis (Edwards Sapien XT). No complications were detected during the procedure guided by transesophageal echocardiography (TEE) (Video 1 of the supplementary material). Posterior transthoracic echocardiography (TTE) demonstrated a normal mean transvalvular gradient (Figure 1A-1B). The patient was discharged with antithrombotic treatment consisting of aspirin 100mg/d indefinitely and clopidogrel 75mg/d for 3 months. One year later, the patient was admitted with inferior ST-segment elevation myocardial infarction and underwent coronary angiography, which showed an abrupt obstruction in the distal part of the posterior descending segment of the right coronary artery, with the typical angiographic appearance of coronary embolism (Figure 1C). Percutaneous coronary intervention was performed with a low profile balloon inflated at very low atmospheres due to the small diameter of the vessel segment where the embolus had stopped (Figure 1D). No evidence of atrial fibrillation during follow-up or hospitalization was observed. Nevertheless, an aortic systolic murmur was detected on exploratory evaluation, with no anemia on laboratory tests or clinical signs of infection. Postprocedural TTE showed an increase in transvalvular aortic gradients compared with a previous study (Figure 2A). The TEE showed an increase in the thickness of the 3 leaflets with restricted motion compared with the previous echocardiographic study, and an aortic valve area of 1.1cm2 assessed by planimetry (Figure 2B-2D, and Video 2 of the supplementary material). With a suspected diagnosis of subclinical leaflet prosthetic thrombosis, anticoagulation consisting of acenocoumarol was initiated. Three months later, a follow-up TTE and TEE showed normal transvalvular aortic gradients (Figure 2E) with thinning of the 3 valvular leaflets (Figure 2F-2H, and Video 3 of the supplementary material).

Figure 1.

TTE continuous wave Doppler and 2-dimensional TEE evaluation post-TAVI. A: Postimplantation follow-up TTE shows normal peak velocity and mean transvalvular gradient. B: TEE in the midesophageal long-axis view depicts thin aortic leaflets (arrows). C, D: Coronary angiography images showing a typical embolism lesion with abrupt closure in the posterior descending artery (C arrow), with posterior recanalization after percutaneous transluminal coronary angioplasty (D arrows). Mean G, mean gradient; PDA, posterior descending artery; Peak V, peak velocity; STEMI, ST-segment elevation myocardial infarction; TAVI, transcatheter aortic valve implantation; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

(0.47MB).
Figure 2.

TTE continuous wave Doppler, TEE in 2-dimensional midesophageal long-axis and TEE in 2-dimensional short-axis views with explanatory colored illustrations. A: One year after TAVI, there is an increase in peak velocity and mean gradient. B: Aortic leaflets are significantly thickened (white arrows). Thrombosis of the 3 leaflets (yellow arrows) in TAVI in diastole (C) and systole (D) with restricted valve opening demonstrated by TEE images. E: After 3 months of anticoagulation therapy, peak velocity and mean gradient have become normal. F: Aortic leaflets again exhibit thinning (white arrows). Thinning of aortic leaflets (yellow arrows) after anticoagulation medication in diastole (G) and systole (H) observed by TEE. Mean G, mean gradient; OACs, oral anticoagulants; Peak V, peak velocity; STEMI, ST-segment elevation myocardial infarction; TAVI, transcatheter aortic valve implantation; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

(0.61MB).

Subclinical leaflet thrombosis in TAVI has been reported in 3% to 4% of patients with balloon-expandable prostheses beyond the first month postprocedure,1,2 and also in other types of TAVI and surgical biological prosthetic valves.3 The diagnosis is based on leaflet thickening and restricted motion detected by echocardiography or multidetector computed tomography.1–3 Nevertheless, in vitro models have shown mean transvalvular gradients to be increased only when at least 2 leaflets are affected, as in our patient.3 These patients are not under anticoagulation therapy or receive antiplatelet medication alone, and anticoagulation therapy is the first option.3 Although these findings have been described as “subclinical” leaflet thrombosis, patients with this complication have recently been reported to have a higher incidence of stroke and transient ischemic attacks.3,4 Coronary thrombosis has been reported during TAVI.5 However, there have been no previous reports of coronary embolism in the chronic phase secondary to leaflet thrombosis in TAVI, as in our patient. These complications raise the need to review imaging follow-up protocols and antiplatelet/anticoagulation therapy in TAVI patients during the first year after implantation.

SUPPLEMENTARY MATERIAL

(0.3MB)
(0.31MB)
(0.87MB)

References
[1]
T. Leetmaa, N.C. Hansson, J. Leipsic, et al.
Early aortic transcatheter heart valve thrombosis: diagnostic value of contrast-enhanced multidetector computed tomography.
Circ Cardiovasc Interv., (2015),
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.114.001596
[2]
M. Abdel-Wahab, F.J. Neumann, J. Mehilli, et al.
1-Year Outcomes After Transcatheter Aortic Valve Replacement With Balloon-Expandable Versus Self-Expandable Valves: Results From the CHOICE Randomized Clinical Trial.
J Am Coll Cardiol., 66 (2015), pp. 791-800
[3]
R.R. Makkar, G. Fontana, H. Jilaihawi, et al.
Possible Subclinical Leaflet Thrombosis in Bioprosthetic Aortic Valves.
N Engl J Med., 373 (2015), pp. 2015-2024
[4]
P. Salinas, R. Moreno, L. Calvo, et al.
Long-term follow-up after transcatheter aortic valve implantation for severe aortic stenosis.
Rev Esp Cardiol., 69 (2016), pp. 37-44
[5]
R. Mori Junco, F. Domínguez Melcón, M. Moreno Yangüela.
Coronary obstruction during transcatheter aortic valve replacement.
Rev Esp Cardiol., 68 (2015), pp. 893
Copyright © 2016. Sociedad Española de Cardiología
Idiomas
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

Article options
  • Léalo en español
  • Download PDF
  • Bibliography
  • NOTICE Array to string conversion (includes_ws_v2/librerias/html/item.php[1302])
    NOTICE Array to string conversion (includes_ws_v2/librerias/html/item.php[1302])
    NOTICE Array to string conversion (includes_ws_v2/librerias/html/item.php[1302])
  • Additional material
Tools
NOTICE Array to string conversion (includes_ws_v2/librerias/html/item.php[1302])
NOTICE Array to string conversion (includes_ws_v2/librerias/html/item.php[1302])
NOTICE Array to string conversion (includes_ws_v2/librerias/html/item.php[1302])
Supplemental materials
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.