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Course of early subclinical leaflet thrombosis after transcatheter aortic valve implantation with or without oral anticoagulation

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Abstract

Background

After transcatheter aortic valve implantation, early leaflet thickening, presumably reflecting thrombus, has recently been described on computed tomography angiography (CTA) in ~10% of the patients. We sought to investigate the impact of the antithrombotic regimen on the course of leaflet thickening.

Methods

The study comprised 51 patients with leaflet thickening. Based on the time period, patients without an established indication for anticoagulation were put on phenprocoumon plus clopidogrel for at least 3 months or on dual antiplatelet therapy with aspirin and clopidogrel. Follow-up CTAs were evaluated for leaflet restriction, assessed by four-point-grading score, and maximal thickness.

Findings

The anticoagulation and the dual antiplatelet therapy group comprised 29 and 22 patients, respectively. After a median of 86 days, we obtained follow-up CTAs in 22 patients on anticoagulation and in 16 patients on dual antiplatelet therapy. Leaflet thickening progressed in 11 on dual antiplatelet therapy, but always regressed onanticoagulation. The course of leaflet restriction and maximal thickness was significantly different between the two groups (P < 0.001): in the dual antiplatelet therapy group, maximal thickness increased by a mean of 1.37 ± 1.67 mm (P = 0.005) and leaflet restriction score by a median 1[quartiles 0;2] (P = 0.013), whereas in the anticoagulation group, maximal thickness regressed by 2.57 ± 1.52 mm (P < 0.001) and leaflet restriction score decreased by 1[−4;0] (P = 0.001). After a median of 91 days after discontinuation of anticoagulation, CTA performed in ten patients revealed a significant recurrent increase in leaflet restriction score and maximal thickness (P = 0.023, P = 0.007). In the entire cohort, changes in leaflet restriction correlated significantly with changes in transvalvular pressure gradients (r = 0.511, P < 0.001).

Interpretation

The course of leaflet restriction was fundamentally different depending on the presence or absence of anticoagulation, with consistent regression under phenprocoumon, but mostly progression under antiplatelet therapy alone. Changes in leaflet restriction were associated with changes in transvalvular pressure gradients.

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Authors and Affiliations

  1. Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany

    Philipp Ruile, Nikolaus Jander, Simon Schoechlin, Michael Gick, Juergen Rothe, Heinz-Joachim Buettner & Franz-Josef Neumann

  2. Center for Heart Valve Innovation, St. Paul’s Hospital and University of British Columbia, Vancouver, Canada

    Philipp Blanke & Jonathon Leipsic

  3. Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany

    Jochen Reinöhl

  4. Department of Radiology, Section of Cardiovascular Radiology, University of Freiburg, Freiburg im Breisgau, Germany

    Mathias Langer & Gregor Pache

Authors
  1. Philipp Ruile
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  2. Nikolaus Jander
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  3. Philipp Blanke
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  4. Simon Schoechlin
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  5. Jochen Reinöhl
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  6. Michael Gick
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  7. Juergen Rothe
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  8. Mathias Langer
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  9. Jonathon Leipsic
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  10. Heinz-Joachim Buettner
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  11. Franz-Josef Neumann
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  12. Gregor Pache
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Corresponding author

Correspondence to Philipp Ruile.

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Conflict of interest

Dr. Blanke: consultant for Edwards Lifesciences Inc. and Neovasc., Dr. Leipsic: consultant and Corelab for Edwards Lifesciences, Corelab Medtronic, and Dr. Pache: consultant for Edwards Lifesciences Inc.

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Ruile, P., Jander, N., Blanke, P. et al. Course of early subclinical leaflet thrombosis after transcatheter aortic valve implantation with or without oral anticoagulation. Clin Res Cardiol 106, 85–95 (2017). https://doi.org/10.1007/s00392-016-1052-3

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  • DOI: https://doi.org/10.1007/s00392-016-1052-3

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