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Valvular and perivalvular thrombus after TAVR: Risks and Outcomes

26 Feb 2024

Transcatheter aortic valve replacement (TAVR) is the standard treatment for severe aortic stenosis, but post-TAVR leaflet thrombus, identified by hypoattenuated leaflet thickening (HALT), poses potential risks like cerebral thromboembolic events. Perivalvular thrombus has also been reported. The ADAPT-TAVR study compared edoxaban with dual antiplatelet therapy (DAPT) to prevent leaflet thrombus and associated risks post-TAVR. As a dedicated substudy of ADAPT-TAVR, investigators analyzed the frequency, predictors, and clinical progression of subclinical advanced imaging phenomena related to aortic valve thrombus.

In this study, where edoxaban was compared to dual antiplatelet therapy in TAVR patients without a chronic anticoagulation indication, a comprehensive evaluation was conducted using 4-dimensional computed tomography at the 6-month mark. This sub-study aimed to assess the frequency of both valvular (subclinical leaflet thrombus) and perivalvular (supravalvular, subvalvular, and sinus of Valsalva) thrombus and their potential association with various clinical outcomes.

Among the 211 patients subjected to 6-month computed tomography evaluations, the findings revealed that 43.1% had thrombus at any aortic valve complex. Specifically, 14.2% of patients exhibited leaflet thrombus, while 37.0% had perivalvular thrombus. Independent predictors of aortic valve complex and perivalvular thrombus included a small maximum stent diameter at the valve level and a low body surface area. Additionally, decreased renal function emerged as an independent predictor of leaflet thrombus.

Despite the prevalence of subclinical aortic valve complex thrombus following successful TAVR, the study did not find any significant associations between these imaging phenomena and adverse outcomes. Specifically, there were no notable differences observed in terms of new cerebral lesions, neurologic or neurocognitive dysfunction, or overall clinical outcomes between patients with or without valvular or perivalvular thrombus. The authors concluded that while subclinical thrombus in the aortic valve complex was common post-TAVR, it did not appear to contribute to negative neurological or clinical consequences.

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Original article: Choi Y et al. J Am Coll Cardiol Intv 2023;16:2967–2981.

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