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Jung S, Ammon F, Smolka S, Moshage M, Marwan M, Achenbach S. Commissural misalignment independently predicts leaflet thrombosis after transcatheter aortic valve implantation. Clin Res Cardiol 2024; 113:29-37. [PMID: 37022472 PMCID: PMC10808532 DOI: 10.1007/s00392-023-02192-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/24/2023] [Indexed: 04/07/2023]
Abstract
AIMS Transcatheter aortic valve implantation (TAVI) has become a minimally invasive alternative to surgical aortic valve replacement. Hypo-attenuated leaflet thickening (HALT)-a marker of subclinical leaflet thrombosis commonly detected by cardiac computed tomography (CT) after TAVI-may influence valve durability and function. The purpose of this study was to compare commissural alignment of the native and prosthetic aortic valves in cardiac CT in subjects with and without HALT and thereby identify commissural misalignment as potential predictor for leaflet thrombosis after TAVI. METHODS AND RESULTS In 170 subjects, 85 with and 85 without HALT in post-TAVI CT, commissural orientation of the prosthesis was determined comparing native and prosthetic aortic valve orientation in cardiac CT by measuring the commissural angle relative to the right coronary ostium in the aortic valve plane. For the prosthetic valve, any deviation ≤ 15° compared to the native valve was classified as "aligned"; 16-30° as "mild", 31-45° as "moderate" and ≥ 45° as "severe" misalignment. Among subjects with HALT, median angular deviation was higher (36°, IQR 31°) than in the control group (29°, IQR 29°, p = 0.042). "Severe" misalignment was more frequent in subjects who developed HALT (n = 31, 37%) compared to the control group (n = 17, 20%, p = 0.013). In logistic regression analysis, more severe deviation (p = 0.015, OR = 1.02 per 1° deviation) and "severe" misalignment (p = 0.018, OR = 2.2) represented independent predictors for the occurrence of HALT after TAVI. CONCLUSION Subclinical leaflet thrombosis after TAVI is associated with commissural misalignment. Potential clinical advantages of obtaining commissural alignment remain to be systematically assessed.
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Affiliation(s)
- Susanne Jung
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany.
| | - Fabian Ammon
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Silvia Smolka
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Maximilian Moshage
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
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2
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Rashid HN, Rajani R, Leipsic J, Maurovitch-Horvat P, Patterson T, Redwood S, Lee J, Hurrell H, Nicholls SJ, Nasis A, Seneviratne S, Cameron JD, Prendergast B, Gooley RP. Computed tomography imaging for subclinical leaflet thrombosis following surgical and transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr 2023; 17:2-10. [PMID: 36396555 DOI: 10.1016/j.jcct.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Subclinical leaflet thrombosis (LT) may occur following surgical and transcatheter aortic valve replacement. Computed tomography (CT) has become an established imaging modality to diagnose subclinical LT following bioprosthetic aortic valve replacement. Even so, there is a limited (but growing) experience in utilizing CT imaging for this indication. This review emphasizes a systematic approach to acquiring and analysing CT imaging for subclinical LT, highlighting evidence surrounding clinical sequelae of subclinical LT and anti-thrombotic implications following diagnosis.
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Affiliation(s)
- Hashrul N Rashid
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia; Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom.
| | - Ronak Rajani
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Pál Maurovitch-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary.
| | - Tiffany Patterson
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom; School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom.
| | - Simon Redwood
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom; School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom.
| | - Jack Lee
- Biomedical Engineering Department, King's College London, London, United Kingdom.
| | - Harriet Hurrell
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom; School of Cardiovascular Medicine & Sciences, King's College London, London, United Kingdom.
| | - Stephen J Nicholls
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Arthur Nasis
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Sujith Seneviratne
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - James D Cameron
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Bernard Prendergast
- Department of Cardiology, Guy's & St. Thomas' Hospital, London, United Kingdom.
| | - Robert P Gooley
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
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Esmailie F, Razavi A, Yeats B, Sivakumar SK, Chen H, Samaee M, Shah IA, Veneziani A, Yadav P, Thourani VH, Dasi LP. Biomechanics of Transcatheter Aortic Valve Replacement Complications and Computational Predictive Modeling. Struct Heart 2022; 6:100032. [PMID: 37273734 PMCID: PMC10236878 DOI: 10.1016/j.shj.2022.100032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/09/2021] [Accepted: 11/03/2021] [Indexed: 06/06/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is a rapidly growing field enabling replacement of diseased aortic valves without the need for open heart surgery. However, due to the nature of the procedure and nonremoval of the diseased tissue, there are rates of complications ranging from tissue rupture and coronary obstruction to paravalvular leak, valve thrombosis, and permanent pacemaker implantation. In recent years, computational modeling has shown a great deal of promise in its capabilities to understand the biomechanical implications of TAVR as well as help preoperatively predict risks inherent to device-patient-specific anatomy biomechanical interaction. This includes intricate replication of stent and leaflet designs and tested and validated simulated deployments with structural and fluid mechanical simulations. This review outlines current biomechanical understanding of device-related complications from TAVR and related predictive strategies using computational modeling. An outlook on future modeling strategies highlighting reduced order modeling which could significantly reduce the high time and cost that are required for computational prediction of TAVR outcomes is presented in this review paper. A summary of current commercial/in-development software is presented in the final section.
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Affiliation(s)
- Fateme Esmailie
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Atefeh Razavi
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Breandan Yeats
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sri Krishna Sivakumar
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Huang Chen
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Milad Samaee
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Imran A. Shah
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alessandro Veneziani
- Department of Mathematics, Department of Computer Science, Emory University, Atlanta, Georgia, USA
| | - Pradeep Yadav
- Department of Cardiology, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Vinod H. Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Lakshmi Prasad Dasi
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University School of Medicine, Atlanta, Georgia, USA
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Rashid HN, Cameron JD, Gooley RP. Early Bioprosthetic Valve Dysfunction Following TAVR: The Role of CT Imaging in Diagnosing Acute Leaflet Thrombosis. Heart Lung Circ 2022; 31:e120-e122. [PMID: 35513965 DOI: 10.1016/j.hlc.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/20/2022] [Accepted: 03/27/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Hashrul N Rashid
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia.
| | - James D Cameron
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia
| | - Robert P Gooley
- MonashHeart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia
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Rashid HN, Michail M, Ihdayhid AR, Khav N, Tan S, Nasis A, Nicholls SJ, Cameron JD, Gooley RP. Prosthesis Geometrical Predictors of Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement With Intra-Annular Prostheses. Heart Lung Circ 2022; 31:678-84. [PMID: 35065896 DOI: 10.1016/j.hlc.2021.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/25/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the association between prosthesis geometry with leaflet thrombosis (LT). BACKGROUND Leaflet thrombosis following transcatheter aortic valve replacement (TAVR) is a recognised entity. The association between prosthesis geometry with LT is unclear but maybe a potential modifiable factor in its prevention. METHODS Patients who received an intra-annular TAVR prosthesis and were prospectively planned to undergo post-procedural computed tomography (CT) imaging were included. Leaflet thrombosis was defined as at least 50% restricted leaflet motion on CT. Prosthesis expansion and eccentricity was measured at prosthesis inflow, annulus and outflow levels. Prosthesis misalignment was defined as the average angle deviation between native and prosthesis leaflet commissure, greater than 30°. RESULTS Prevalence of LT was 13.7% in 117 patients. None of the patients with LT were on anticoagulation therapy. Patients with LT had reduced prosthesis annular expansion (89.4±5.2% vs 97.0±4.4%, p<0.01), greater prosthesis misalignment (81.3% vs 48.5%, p=0.02) and deeper implants (6.3±1.7 mm vs 4.3±1.5 mm, p<0.01). Threshold for the presence of LT on ROC analysis was an implant depth of 5.7 mm (AUC [area under curve]=0.81). Independent predictors of LT were annular under-expansion (Odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.7, p=0.03) prosthesis misalignment (OR 6.8, 95%CI 1.1-45.5, p=0.04) and implant depth (OR 1.9, 95%CI 1.1-3.2, p=0.03). Anticoagulation therapy was a protective factor (OR 0.2; 95%CI 0.1-0.4, p<0.01). CONCLUSION Geometrical predictors of LT post intra-annular TAVR were reduced prosthesis expansion at the annular level, lower implant depth and greater prosthesis misalignment. These factors may be important considerations during procedural planning for TAVR.
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Hatoum H, Singh-Gryzbon S, Esmailie F, Ruile P, Neumann FJ, Blanke P, Thourani VH, Yoganathan AP, Dasi LP. Predictive Model for Thrombus Formation After Transcatheter Valve Replacement. Cardiovasc Eng Technol 2021; 12:576-588. [PMID: 34859378 PMCID: PMC11034843 DOI: 10.1007/s13239-021-00596-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 11/09/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE Leaflet thrombosis is a significant adverse event after transcatheter aortic valve (TAV) replacement (TAVR). The purpose of our study was to present a semi-empirical, mathematical model that links patient-specific anatomic, valve, and flow parameters to predict likelihood of leaflet thrombosis. METHODS The two main energy sources of neo-sinus (NS) washout after TAVR include the jet flow downstream of the TAV and NS geometric change in volume due to the leaflets opening and closing. Both are highly dependent on patient anatomic and hemodynamic factors. As rotation of blood flow is prevalent in both the sinus of Valsalva and then the NS, we adopted the vorticity flux or circulation (Г) as a metric quantifying overall washout. Leaflet thrombus volumes were segmented based on hypo-attenuating leaflet thickening (HALT) in post-TAVR patient's gated computed tomography. Г was assessed using dimensional scaling as well as computational fluid dynamics (CFD) respectively and correlated to the thrombosis volumes using sensitivity and specificity analysis. RESULTS Г in the NS, that accounted for patient flow and anatomic conditions derived from scaling arguments significantly better predicted the occurrence of leaflet thrombus than CFD derived measures such as stasis volumes or wall shear stress. Given results from the six patient datasets considered herein, a threshold Г value of 28.0 yielded a sensitivity and specificity of 100% where patients with Gamma < 28 developed valve thrombosis. A 10% error in measurements of all variables can bring the sensitivity specificity down to 87%. CONCLUSION A predictive model relating likelihood of valve thrombosis using Г in the NS was developed with promising sensitivity and specificity. With further studies and improvements, this predictive technology may lead to alerting physicians on the risk for thrombus formation following TAVR.
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Affiliation(s)
- Hoda Hatoum
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313, USA
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, USA
| | - Shelly Singh-Gryzbon
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313, USA
- Department of Chemical & Process Engineering, The University of the West Indies, St Augustine, Trinidad and Tobago
| | - Fateme Esmailie
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313, USA
| | - Philipp Ruile
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Philipp Blanke
- University of British Columbia and St. Paul's Hospital in Vancouver, Vancouver, Canada
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Ajit P Yoganathan
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313, USA
| | - Lakshmi Prasad Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313, USA.
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Rashid HN, Michail M, Ramnarain J, Nasis A, Nicholls SJ, Cameron JD, Gooley RP. The impact of hypo-attenuated leaflet thickening on haemodynamic valve deterioration following transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr 2021; 16:168-173. [PMID: 34852974 DOI: 10.1016/j.jcct.2021.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/10/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hypo-attenuated leaflet thickening (HALT) may occur following transcatheter aortic valve replacement (TAVR), however, it remains unclear if HALT is a predictor of haemodynamic valve deterioration (HVD). AIM To determine the impact of HALT on the occurrence of HVD. METHODS We prospectively evaluated 186 patients for the presence of HALT at a median of 6 weeks following TAVR (Interquartile-range [IQR] 4-12 weeks). HALT depth and area were measured. HVD encompassed any of the following: mean gradient ≥20 mmHg with an increase in gradient ≥10 mmHg from baseline, Doppler velocity index reduction ≥0.1 or new moderate-to-severe valvular regurgitation. Routine echocardiograms at discharge, one month and annually, were assessed by echo-cardiologists that were blinded to the HALT status. RESULTS LT prevalence was 17.7% (33/186). HVD was present in 8.6% (16/186) at a median follow-up of 2 years (IQR 1-3); two required valve re-intervention and five required anticoagulation. HALT was the only independent predictor of HVD on multivariate analysis (OR 33.3, 95%CI 7.4-125). Patients with HALT were more likely to develop HVD, require repeat valve intervention and have higher trans-valvular gradients at up to 3-year follow-up. Patients with HALT had a median cumulative thickness of 2.9 mm (IQR 1.9-4.7) and area of 64.2 mm2 (IQR 40.9-91.6). Thresholds for HALT in predicting HVD were a cumulative depth of 2.4 mm (Specificity 94.1%, Sensitivity 75.0%, AUC = 0.87) and cumulative area of 28 mm2 (Specificity 92.2%, Sensitivity 81.3%, AUC = 0.86). CONCLUSION HALT is an independent predictor of HVD, which exhibits specific depth and area thresholds to predict HVD. CT following TAVR may determine patients at risk of HVD.
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Affiliation(s)
- Hashrul N Rashid
- Monash Heart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Australia.
| | - Michael Michail
- Sussex Cardiac Centre, University Hospital Sussex NHS Trust, Brighton, United Kingdom
| | - Jaineel Ramnarain
- Monash Heart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Australia
| | - Arthur Nasis
- Monash Heart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Australia
| | - Stephen J Nicholls
- Monash Heart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Australia
| | - James D Cameron
- Monash Heart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Australia
| | - Robert P Gooley
- Monash Heart, Monash Health and Monash Cardiovascular Research Centre, Monash University, Australia
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Bailoor S, Seo JH, Dasi LP, Schena S, Mittal R. A computational study of the hemodynamics of bioprosthetic aortic valves with reduced leaflet motion. J Biomech 2021; 120:110350. [PMID: 33743394 DOI: 10.1016/j.jbiomech.2021.110350] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 01/25/2023]
Abstract
We employ a reduced degree-of-freedom aortic valve model to investigate the flow physics associated with early-stage reduced leaflet motion in bioprosthetic aortic valves. The model is coupled with a sharp-interface immersed boundary based incompressible flow solver to efficiently simulate the fluid-structure interaction. A total of 19 cases of flow through aortic valves with varying degrees of reduced leaflet motion (RLM) are considered. The characteristics of the aortic jet and the consequent aorta wall loading patterns are analyzed. Our results show that asymmetric RLM tilts the aortic jet and leads to large reverse and recirculating flow regions downstream from leaflets with restricted mobility. The changes in flow patterns increase wall pressure and shear stress fluctuations, and result in asymmetric oscillating shear on the aorta wall. These findings have implications for auscultation based diagnosis of this condition as well as the health of the aorta.
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Rashid HN, Michail M, Ihdayhid AR, Dowling C, Khav N, Tan S, Ramnarain J, Cameron JD, Nasis A, Nicholls SJ, Gooley RP. Clinical predictors and sequelae of computed tomography defined leaflet thrombosis following transcatheter aortic valve replacement at medium-term follow-up. Heart Vessels 2021; 36:1374-83. [PMID: 33660057 DOI: 10.1007/s00380-021-01803-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The clinical predictors and sequelae of leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is still unclear. Therefore, our aim was to determine the clinical predictors and sequelae at mid-term follow-up of computed tomography (CT)-defined LT following TAVR. METHODS AND RESULTS We performed a prospective evaluation with a 320-multislice CT following TAVR for the presence of LT, defined as hypo-attenuated leaflet thickening (HALT). Four-dimensional CT image-rendering was performed to determine the presence of reduced leaflet motion (RELM). 172 patients [89 (51.7%) male, mean age 82.8 ± 5.7 years] treated with commercially available TAVR device (Lotus 54%, CoreValve 32% and Sapien 3 14%) were included, with median CT-scan at 6.0 weeks post-TAVR. Prevalence of HALT was 14.0% (24 cases) and RELM was 9.8% (17 cases). On multivariate analysis, patients with HALT were less prescribed oral anticoagulation (OAC) (OR 9.9), received larger TAVR prostheses (OR 5.7) and higher rates of moderate-severe para-valvular regurgitation (PVR) (OR 16.3). There was no difference in clinical outcomes at a median follow-up of 2.3 years. Patients with RELM had significantly higher transvalvular gradients after discharge when compared to those without RELM. CONCLUSIONS Absence of OAC, large TAVR prostheses and moderate-severe PVR were predictors for LT. Transvalvular gradients were higher in patients that developed RELM but not HALT. Further studies are warranted to determine the long-term impact of LT on TAVR durability. Prevalence of different sub-types of CT-defined LT (HALT and RELM) and the clinical predictors of developing LT following TAVR. CT computed tomography, HALT hypo-attenuated leaflet thickening, LT leaflet thrombosis, RELM reduced leaflet motion, TAVR transcatheter aortic valve replacement.
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Ncho B, Sadri V, Ortner J, Kollapaneni S, Yoganathan A. In-Vitro Assessment of the Effects of Transcatheter Aortic Valve Leaflet Design on Neo-Sinus Geometry and Flow. Ann Biomed Eng 2021; 49:1046-57. [PMID: 33098058 DOI: 10.1007/s10439-020-02664-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
Transcatheter aortic valve (TAV) leaflet thrombosis is a clinical risk with potentially fatal consequences. Studies have identified neo-sinus flow stasis as a cause of leaflet thrombosis. Flow stasis is influenced by the TAV leaflets, which affect the local fluid dynamics in the aortic sinus and neo-sinus. This study evaluated the effects of TAV leaflet features on the neo-sinus flow as a measure of leaflet thrombosis risk. Five TAVs of varied leaflet length and insertion height were tested in a simulator. Hydrodynamics and leaflet kinematics through en-phase imaging were quantified. Velocity fields were assessed using high-speed particle image velocimetry. Regions of flow stasis and particle residence times (PRTs) were quantified. TAVs with shorter leaflet length exhibited larger orifice areas and lower transvalvular pressure gradients. Shorter leaflet length and increased leaflet insertion TAVs additionally exhibited lower neo-sinus PRTs (0.44 ± 0.21 vs 2.83 ± 0.48 cycles, p < 0.05) and higher neo-sinus peak velocities (0.15 ± 0.009 vs 0.07 ± 0.005 m/s, p < 0.05) than TAVs with longer leaflet length and lower leaflet insertion. The average neo-sinus volume positively correlated with PRT(r = 0.810, p < 0.001), and extent of flow stasis (r = 0.682, p < 0.05). These results suggest that a small neo-sinus volume may reduce flow stagnation and particle residence, potentially reducing the risk of leaflet thrombosis. We propose that leaflet design features might be proactively controlled in the design of future transcatheter aortic valves.
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Khav N, Rashid HN, Brown AJ. The role of four-dimensional computed tomography in transcatheter aortic valve replacement prosthesis endocarditis with concurrent leaflet thrombosis: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33426456 PMCID: PMC7780482 DOI: 10.1093/ehjcr/ytaa252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/16/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022]
Abstract
Background Transcatheter aortic valve replacement (TAVR) is becoming increasingly utilized for the treatment of severe aortic valvular heart disease. Infective endocarditis of TAVR is rare but associated with higher mortality and morbidity. The potential for leaflet thrombosis following TAVR is also becoming increasingly recognized. Diagnosis of these conditions on echocardiography can be challenging due to prosthesis artefact. Case summary An 84-year-old man with a previous transcatheter aortic valve replacement presented with a febrile illness and bacteraemia. Transthoracic and transoesophageal echocardiography demonstrated high transvalvular gradients with features of prosthesis endocarditis, though leaflet morphology could not be fully assessed due to prosthesis artefact. Four-dimensional computed tomography revealed hypo-attenuated leaflet thickening with reduced leaflet motion, consistent with prosthesis leaflet thrombosis. The patient was successfully treated with antibiotics and anticoagulation, with resolution of the infection and normalization of the transvalvular gradient after 6 weeks. Discussion Echocardiography should be the first-line investigation for assessing leaflet morphology in suspected prosthetic valve endocarditis or leaflet thrombosis but its accuracy may be limited by artefact. Our case highlights that four-dimensional computed tomography provides further evaluation of prosthesis leaflet morphology/motion, providing valuable diagnostic information.
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Affiliation(s)
- Nancy Khav
- Monash Cardiovascular Research Centre and Monash Heart, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia
| | - Hashrul N Rashid
- Monash Cardiovascular Research Centre and Monash Heart, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia
| | - Adam J Brown
- Monash Cardiovascular Research Centre and Monash Heart, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia
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Hosoba S, Mori M, Goto Y, Fukumoto Y, Shimura T, Yamamoto M. Hypo-attenuated leaflet thickening in surgically-implanted mitral bioprosthesis. J Cardiothorac Surg 2020; 15:74. [PMID: 32381038 PMCID: PMC7206689 DOI: 10.1186/s13019-020-01120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/28/2020] [Indexed: 11/28/2022] Open
Abstract
Background Hypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT. Methods A single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT. Results Three patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation. Conclusions In this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.
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Affiliation(s)
- Soh Hosoba
- Division of Cardiovascular Surgery, Toyohashi Heart Center, 21 Gofuntori, Oyamacho, Toyohashi, Aichi, 4418530, Japan.
| | - Makoto Mori
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Yoshihiro Goto
- Division of Cardiovascular Surgery, Toyohashi Heart Center, 21 Gofuntori, Oyamacho, Toyohashi, Aichi, 4418530, Japan
| | - Yuichiro Fukumoto
- Division of Cardiovascular Surgery, Toyohashi Heart Center, 21 Gofuntori, Oyamacho, Toyohashi, Aichi, 4418530, Japan
| | - Tetsuro Shimura
- Division of Cardiology, Toyohashi Heart Center, Toyohashi, Japan
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Hatoum H, Maureira P, Lilly S, Dasi LP. Impact of BASILICA on Sinus and Neo-Sinus Hemodynamics after Valve-in-Valve with and without Coronary Flow. Cardiovasc Revasc Med 2019; 21:271-276. [PMID: 31281093 DOI: 10.1016/j.carrev.2019.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE This study aims at evaluating the impact of BASILICA on neo-sinus and sinus hemodynamics with and without coronary flow. Leaflet thrombosis after valve-in-valve (ViV) may compromise not only leaflet mobility but also affect valve durability and performance. METHODS/MATERIALS In a 23 mm transparent surgical aortic valve model, a 23 mm Edwards SAPIEN 3 and a 26 mm Medtronic Evolut were deployed before and after leaflet laceration, in models with and without coronary flow. Neo-sinus and sinus hemodynamics were evaluated in the aortic position of a pulse duplicator and particle image velocimetry was performed in order to quantify sinus flow hemodynamics along with sinus and neo-sinus washout. RESULTS BASILICA-type leaflet laceration procedure led to (a) an increase in the velocities in the sinus and the neo-sinus by 50% for Evolut ViV with and without coronary flow, 70% for non-coronary SAPIEN 3 ViV and 10% for coronary SAPIEN 3 ViV, and (b) an improvement in overall washout up to 2 cycles in the neo-sinus and 0.5 cycles in the sinus. CONCLUSIONS A BASILICA-type leaflet laceration approach may improve sinus and neo-sinus hemodynamics through decreasing flow stasis and enabling less confined blood flow. BASILICA confers coronary sinus flow patterns to the non-coronary sinus.
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Affiliation(s)
- Hoda Hatoum
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA
| | - Pablo Maureira
- Department of Cardiovascular Surgery, CHU de Nancy, Nancy, France
| | - Scott Lilly
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Lakshmi Prasad Dasi
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA.
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Khan S, Achike O, Nekkanti R, Carabello B. Successful Apixaban Treatment of TAVR Thrombosis after Warfarin Failure. Cardiology 2018; 140:199-203. [PMID: 30138936 DOI: 10.1159/000491077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/19/2022]
Abstract
In this study, we present a case of progressive transcatheter aortic valve replacement thrombosis in a patient receiving warfarin that resolved with treatment with heparin and apixaban.
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Affiliation(s)
- Saleen Khan
- Department of Internal Medicine, East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
| | - Olisaemeka Achike
- Department of Cardiovascular Sciences, East Carolina Heart Institute, Greenville, North Carolina, USA
| | - Rajasekhar Nekkanti
- Department of Cardiovascular Sciences, East Carolina Heart Institute, Greenville, North Carolina, USA
| | - Blase Carabello
- Department of Cardiovascular Sciences, East Carolina Heart Institute, Greenville, North Carolina, USA
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Alkhouli M, Winkler L, Tallaksen RJ. Computed Tomography Assessment for Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2018; 7:301-313. [PMID: 29983143 DOI: 10.1016/j.iccl.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Transcatheter aortic valve replacement has become a mainstream therapeutic option for patients with severe aortic stenosis who are at intermediate risk or high risk for surgical valve replacement. Computed tomography (CT) is now the standard imaging modality for preoperative vascular access planning an aortic annular sizing. This article reviews the established and potential future roles of CT in transcatheter aortic valve replacement.
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Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiovascular Disease, Structural Heart Interventions, West Virginia University School of Medicine, West Virginia University, 1 Medical Center Drive, Morgantown, WV 26505-8059, USA.
| | - Lana Winkler
- Department of Radiology, West Virginia University, 1 medical drive, Morgantown, WV 26505, USA
| | - Robert J Tallaksen
- Department of Radiology, West Virginia University, 1 medical drive, Morgantown, WV 26505, USA
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Zhao ZG, Wang MY, Jilaihawi H. Imaging Evaluation for the Detection of Leaflet Thrombosis After Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2018; 7:293-9. [PMID: 29983142 DOI: 10.1016/j.iccl.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Subclinical leaflet thrombosis has been increasingly recognized as a common imaging finding after surgical or transcatheter aortic valve replacement (TAVR) in recent studies. This finding has raised concerns over TAVR valve durability and debates on optimal postprocedural antithrombotic regime. Hypoattenuated leaflet thickening (HALT) and the associated reduced leaflet motion (RELM) were noted as computed tomography hallmarks of the phenomenon. The coexistence of HALT and significant RELM has been suggested as a threshold for reporting of subclinical leaflet thrombosis. This methodology may contribute to the standardization of reporting for research collaboration, hence the better understanding and management of this common yet largely unknown phenomenon.
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Marwan M, Mekkhala N, Göller M, Röther J, Bittner D, Schuhbaeck A, Hell M, Muschiol G, Kolwelter J, Feyrer R, Schlundt C, Achenbach S, Arnold M. Leaflet thrombosis following transcatheter aortic valve implantation. J Cardiovasc Comput Tomogr 2017; 12:8-13. [PMID: 29195844 DOI: 10.1016/j.jcct.2017.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 10/29/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is increasingly being offered to high-risk patients with symptomatic aortic valve stenosis. Recent reports have suggested a high incidence of subclinical leaflet thrombosis following bioprosthestic aortic valve replacement. We report the frequency and clinical presentation of leaflet thrombosis identified by cardiac CT in patients referred for follow-up contrast enhanced CT angiography following TAVI. METHODS 91 consecutive patients referred for follow-up contrast-enhanced CT angiography following TAVI were screened for inclusion in this analysis. Out of these, 13 patients were excluded. All CT examinations were performed using a 2nd or a 3rd generation dual-source system (Somatom Definition Flash/Force, Forchheim, Germany). In all patients, retrospectively ECG-gated spiral acquisition with tube modulation was performed to allow for assessment of leaflet motion. All prostheses were analyzed for presence of leaflet thrombosis defined as hypo-attenuated leaflet thickening with or without leaflet restriction. Post-procedural antithrombotic regimen as well as symptom status was documented in all patients. RESULTS 78 consecutive patients (35 males, 81 ± 4 years) were analyzed. TAVI had been performed in all patients (76 transfemoral access, 2 transapical access) with either balloon-expandable prostheses (4 Sapien XT, 64 Sapien 3) or self-expandable prostheses (5 SJM Portico, 5 Symetis Acurate). Follow-up CT angiography was performed at a median of 4 months following index procedure (Interquartile range 1 month). Leaflet thrombosis was detected in 18 patients (23%, 14 Sapien 3, 1 Sapien XT, 2 SJM Portico, 1 Symetis Acurate). In patients with leaflet thickening on CT, only 11% were on either oral anticoagulation or new oral anticoagulants versus 50% for patients with no leaflet thickening (p 0.002). In patients with leaflet thrombosis, 3 leaflets were affected in 5 patients, 2 leaflets in 5 patients and in 8 patient only 1 leaflet was affected. Clinical symptoms (angina, dyspnea or both) were reported in 2/18 patients with leaflet thrombosis (11%) and in both patients a significant increase of the mean echocardiographic gradient over the prosthesis was documented. The peak and mean echocardiographic gradients obtained at the day of CT examination was significantly higher in symptomatic patients versus asymptomatic patients (peak 46 ± 7 vs. 23 ± 11 mmHg, mean 29 ± 7 vs. 12 ± 6 mmHg, p = 0.01 and 0.002, respectively). Follow-up CT was available for 4 patients with complete resolution of the hypo-attenuated leaflet thickening following treatment. CONCLUSION Leaflet thrombosis following TAVI is a relatively frequent finding in patients referred for contrast enhanced CT angiography following TAVI. In the majority of patients it follows a subclinical course and is substantially more frequent in individuals who are not on oral anticoagulation. However, in patients with relevant increase in prosthetic gradients, symptomatic presentations are possible.
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Affiliation(s)
- M Marwan
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany.
| | - N Mekkhala
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - M Göller
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - J Röther
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - D Bittner
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany; Division of Cardiovascular Imaging, Massachusetts General Hospital, Boston, USA
| | - A Schuhbaeck
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - M Hell
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - G Muschiol
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - J Kolwelter
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - R Feyrer
- Department of Cardiosurgery, University of Erlangen, Germany
| | - C Schlundt
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - S Achenbach
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
| | - M Arnold
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
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