Leaflet Motion Abnormality Following Transcatheter Aortic Valve Implantation



Transcatheter aortic valve implantations (TAVI) are becoming a valid alternative to surgical aortic valve replacement in intermediate-risk patients thanks to technological improvement and increasing operators experience. Before the adoption of this technique in even lower-risk patients, several issues need to be addressed. Transcatheter aortic valve thrombosis is a rare but potentially dramatic complication that may present with recurrence of symptoms, non-ST-elevation myocardial infarction, embolic events, or cardiac arrest. Recently, four-dimensional volume-rendered computed tomography revealed the presence of subclinical leaflet motion abnormalities in patients who underwent both surgical and transcatheter aortic valve replacement. Subclinical leaflet motion abnormalities may result in “hypoattenuated leaflet thickening” (HALT) and/or “reduced leaflet motion” (RELM). Echocardiography, in particular transesophageal echocardiogram, may be helpful to detect limitation of valve motion, leaflet thickening, or increased flow velocity across the prosthetic valve. CT scan acquisition and reconstruction can be deemed as the gold standard imaging tool to visualize thickened leaflets; however it gives no hemodynamic information. These phenomena may occur under dual antiplatelet therapy, while anticoagulation is associated with resolution of thrombosis and restoration of normal leaflet motion. Several studies are ongoing to determine the effect of new oral anticoagulants (NOACs) in preventing leaflet thrombosis and major cardiovascular events.


Leaflet motions TAVI Transcatheter aortic valve implantation Thrombosis Cardiac imaging 


  1. 1.
    Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 2015;385(9986):2477–84.CrossRefGoogle Scholar
  2. 2.
    Midha PA, Raghav V, Sharma R, et al. The fluid mechanics of transcatheter heart valve leaflet thrombosis in the neosinus. Circulation. 2017;136(17):1598–609.CrossRefGoogle Scholar
  3. 3.
    Kappetein AP, Head SJ, Genereux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. J Am Coll Cardiol. 2012;60(15):1438–54.CrossRefGoogle Scholar
  4. 4.
    Latib A, Naganuma T, Abdel-Wahab M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv. 2015;8(4):e001779.CrossRefGoogle Scholar
  5. 5.
    Jose J, Sulimov DS, El-Mawardy M, et al. Clinical bioprosthetic heart valve thrombosis after transcatheter aortic valve replacement: incidence, characteristics, and treatment outcomes. JACC Cardiovasc Interv. 2017;10(7):686–97.CrossRefGoogle Scholar
  6. 6.
    Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic heart valve thrombosis. J Am Coll Cardiol. 2016;68(24):2670–89.CrossRefGoogle Scholar
  7. 7.
    Del Trigo M, Munoz-Garcia AJ, Wijeysundera HC, et al. Incidence, timing, and predictors of valve hemodynamic deterioration after transcatheter aortic valve replacement: multicenter registry. J Am Coll Cardiol. 2016;67(6):644–55.CrossRefGoogle Scholar
  8. 8.
    Paradis JM, Del Trigo M, Puri R, Rodes-Cabau J. Transcatheter valve-in-valve and valve-in-ring for treating aortic and mitral surgical prosthetic dysfunction. J Am Coll Cardiol. 2015;66(18):2019–37.CrossRefGoogle Scholar
  9. 9.
    Mahjoub H, Mathieu P, Senechal M, et al. ApoB/ApoA-I ratio is associated with increased risk of bioprosthetic valve degeneration. J Am Coll Cardiol. 2013;61(7):752–61.CrossRefGoogle Scholar
  10. 10.
    Flameng W, Herregods MC, Vercalsteren M, Herijgers P, Bogaerts K, Meuris B. Prosthesis-patient mismatch predicts structural valve degeneration in bioprosthetic heart valves. Circulation. 2010;121(19):2123–9.CrossRefGoogle Scholar
  11. 11.
    Mahjoub H, Mathieu P, Larose E, et al. Determinants of aortic bioprosthetic valve calcification assessed by multidetector CT. Heart. 2015;101(6):472–7.CrossRefGoogle Scholar
  12. 12.
    Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373(21):2015–24.CrossRefGoogle Scholar
  13. 13.
    Laschinger JC, Wu C, Ibrahim NG, Shuren JE. Reduced leaflet motion in bioprosthetic aortic valves—the FDA perspective. N Engl J Med. 2015;373(21):1996–8.CrossRefGoogle Scholar
  14. 14.
    Pache G, Schoechlin S, Blanke P, et al. Early hypo-attenuated leaflet thickening in balloon-expandable transcatheter aortic heart valves. Eur Heart J. 2016;37(28):2263–71.CrossRefGoogle Scholar
  15. 15.
    Leetmaa T, Hansson NC, Leipsic J, et al. Early aortic transcatheter heart valve thrombosis: diagnostic value of contrast-enhanced multidetector computed tomography. Circ Cardiovasc Interv. 2015;8(4):e001596.CrossRefGoogle Scholar
  16. 16.
    Chakravarty T, Sondergaard L, Friedman J, et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet. 2017;389(10087):2383–92.CrossRefGoogle Scholar
  17. 17.
    Mylotte D, Andalib A, Theriault-Lauzier P, et al. Transcatheter heart valve failure: a systematic review. Eur Heart J. 2015;36(21):1306–27.CrossRefGoogle Scholar
  18. 18.
    Yanagisawa R, Hayashida K, Yamada Y, et al. Incidence, predictors, and mid-term outcomes of possible leaflet thrombosis after TAVR. JACC Cardiovasc Imaging. 2016;
  19. 19.
    Chakravarty T, Abramowitz Y, Jilaihawi H, Makkar RR. Leaflet motion abnormality after TAVI: genuine threat or much ado about nothing? EuroIntervention. 2016;12(Y):Y28–32.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of CardiologyIRCCS Policlinico San Donato, San Donato MilaneseMilanItaly
  2. 2.Department of CardiologyUniversity of CataniaCataniaItaly
  3. 3.Department of CardiologyUniversity of VeronaVeronaItaly

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