Professional Documents
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• Consulting fees/Honoraria
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What is New and Exciting for TAVI
Teams?
Hokkaido, Japan
Risk
6.2% High Risk ( STS >8%) +++ Data
Intermediate Risk
13.9% (STS 4-8%) Partner II
SURTAVI
Durability
Full Steam Ahead
• SURTAVI - STS <4%
• Minimalist Clinical Pathway
– 3M TAVI Trial
• New Indications/Strategies
– Bicuspid, AR, Asymptomatic, Fracking
• HALT
– Hypoattenuating leaflet thickening, PPM
Guideline Update
Lederman, NIH
Pacemaker Post TAVI
Circulation. 2017;;136:1049–1069.
HALT
The n e w e ng l a n d j o u r na l of m e dic i n e
Original Article
http://dx.doi.org/10.1016/j.jacc.2016.08.010 Articles
A BS T R AC T Gregor Pache1*, Simon Schoechlin2, Philipp Blanke3, Stephan Dorfs2, Nikolaus Jander2,
Transcatheter Aortic Valve Thrombosis
BACKGROUND
Chesnal D. Arepalli3, Michael Gick2, Heinz-Joachim Buettner2, Jonathon Leipsic3,
Mathias Langer1, Franz-Josef Neumann2, and Philipp Ruile2
A finding of reduced aortic-valve leaflet motion was noted on computed tomogra- The authors’ full names, academic de-
Incidence, Predisposing Factors, and Clinical Implications grees, and affiliations are listed in Bad
Articles
the Krozingen 79189, Germany; Department of Cardiology & Angiology II,
phy (CT) in a patient who had a stroke after transcatheter aortic-valve replacement
1 2
Department of Radiology, Section of Cardiovascular Radiology, University of Freiburg, Südring15,
3
University Heart Center Freiburg-Bad Krozingen,Appendix.
Bad Krozingen,Address
Germany; andreprint requests to
Center for Heart Valve Innovation, St. Paul’s Hospital & University of British Columbia,
(TAVR) during an ongoing clinical trial. This finding raised
Nicolaj C. Hansson, MD, a
Erik L. Grove, MD, P D, a,b
Henning
sible subclinical leaflet thrombosis and prompted further
H
Vancouver,
R. Andersen,Subclinical leaflet thrombosis in surgical and transcatheter
a concern
Canada
investigation.
Received
MD,
about pos- Dr. Makkar at the Department of Interven-
DMS C ,a
Jonathon Leipsic,
tional
16 April 2015; revised 27 July 2015; accepted
MD,
Cardiology,
18 September
c
2015; Cedars–Sinai Heart In-
online publish-ahead-of-print 7 October 2015
two
Hanssingle-center registries
Erik Bøtker, MD, DMSC, that
a,b Tarun
included
Bjarne
Chakravarty, Lars
132 patients
L. Nørgaard, MD, PHDwho a Subclinical
Søndergaard, were John Friedman,
undergoing leaflet
Ole De
either Backer, thrombosisDaniel
2015, at Berman,
NEJM.org. Klaus inF Kofoed,
was published on October 5,
surgical Hasan Jilaihawi, and transcatheter Takahiro Shiota,
Yigal Abramowitz, Troels H Aims Tanya Rami, Sharjeel
Jørgensen, We sought to evaluate the frequency of early hypo-attenuated leaflet thickening (HALT) of the SAPIEN 3 transcatheter
Israr, Gregory Fontana, Martina de Knegt, Andreas Fuchs, Patrick Lyden,
TAVR or surgical aortic-valve bioprosthesis implantation.bioprosthetic We obtained four-dimen- aortic aortic valve (S3). N valves:
Engl J Med 2015;373:2015-24. an observational study
Alfredo Trento, Deepak L Bhatt,. .Martin
. . . . . . . . . B. .Leon,
. . . . . . . . Raj
. . . . . R. . .Makkar,
. . . . . . . . . . .on
. . . .behalf
. . . . . . . . of
. . . the
. . . . . RESOLVE
. . . . . . . . . . . . .and
. . . . . SAVORY
. . . . . . . . . . . . Investigators*
. . . . . . . . . . . . . . . . . . . . . . .....................................................................
sional, volume-rendered CT scans along with data on anticoagulation and clinical DOI: 10.1056/NEJMoa1509233
ABSTRACT Methods
Tarun Chakravarty, Lars Søndergaard, Of 249John patientsFriedman, who
Copyright Olehad De
© Backer,undergone
2015 Daniel Berman,
Massachusetts S3 implantation,KlausSociety.
Medical F Kofoed, weHasan studied 156Takahiro
Jilaihawi, consecutive
Shiota, patients (85 women, median age
outcomes (including strokes and transient ischemic attacks [TIAs]).
Summary
and results 82.2 + 5.5 years) by electrocardiogram (ECG)-triggered dual-source computed tomography angiography (CTA) after
Yigal Abramowitz, Troels H Jørgensen, Tanya Rami, Sharjeel Israr, Gregory Fontana, Martina de Knegt, Andreas Fuchs, Patrick Lyden,
Alfredo Trento,
Background Subclinical leaflet Deepak L Bhatt,
thrombosis a Martin
of medianB Leon,
of 5 Raj
bioprosthetic R Makkar,
days aortic onvalves
behalf of the
post-transcatheter RESOLVE
aortic
after and SAVORY
valve
transcatheter Investigators*
implantation.
valveThe prosthesis was
replacement assessed Lancet
(TAVR) for HALT. Apart
2017; 389: from
2383–92
RESULTS
BACKGROUND There are limited data on the incidence, clinical implications, and predisposing factors of transcatheter
and surgical aortic valve replacement (SAVR) heparin,
has peri-interventional
been found antithrombotic
with CT imaging.therapy
The consisted
objectiveof single-
of (aspirin
this 29%)was
study or dual-
to (aspirin plus clopidogrel
Published Online
Reduced leaflet
heart valve (THV)motion wasfollowing
thrombosis noted on CT in 22aortic
transcatheter of 55valve
patients
Summary (40%)(TAVR).
replacement in the71%) clinical
antiplatelet therapy. Hypo-attenuated leaflet thickening was found in 16 patients [10.3% (95% confidence
report the prevalence ofBackground
subclinical leaflet thrombosis in ofsurgical and aortic
transcatheter aortic valves and the effect of March 19, 2017 interval
trial and in 17 of 132 patients (13%) in the two registries. Reduced Subclinical
leafletleaflet thrombosis
motion bioprosthetic valves after transcatheter valve replacement (TAVR) Lancet 2017; 389: 2383–92
(CI) 5.5 – 15.0%)] of the patients. None of the baseline and procedural variables were significantly associated with
http://dx.doi.org/10.1016/
HALT
• CT is increasingly being used peri- and
post-procedurally
– Prosthesis position and function
– Leaflet anatomy
• Better spatial resolution than TTE, less
invasive than TEE (and less operator
dependence of interpretation)
• Has led to the identification of unforeseen
findings:
– Hypoattenuating leaflet thickening, reduced
leaflet motion
HALT
• Hypoattenuated thickening, +/-
rigidity/restriction, of one or more leaflets
identifiable in at least 2 different MPR
projections and 2 different reconstruction
time intervals
• Often subclinical (incidentally detected on
CT)
• Involve the periphery and base of the leaflet
with variable extension to the edge of the
leaflet in the centre of the bioprosthetic frame
• Speculated that leaflet thrombosis is the
underlying cause
HALT
• Potential mechanisms:
– Traumatic injury to the leaflets with
deployment of valve
– Leaving native aortic valve cusps in situ may
alter flow dynamics
– Incomplete expansion or over-expansion
could alter mechanical stress on the leaflets
– Increased on-clopidogrel platelet activity in an
elderly population may predispose to
thrombosis
HALT
E F G H
I J K L
M N O P
HALT
© 2017 by the American Heart Association, Inc., and the American College of Cardiology Foundation 27
Subclinical Leaflet Thrombosis