Author + information
- Received November 15, 2016
- Revision received February 13, 2017
- Accepted February 17, 2017
- Published online April 3, 2017.
- Hasan Jilaihawi, MDa,∗ (, )
- Federico M. Asch, MDb,
- Eric Manasse, MDc,
- Carlos E. Ruiz, MDd,
- Vladimir Jelnin, MDd,
- Mohammad Kashif, MDe,
- Hiroyuki Kawamori, MDe,
- Yoshio Maeno, MDe,
- Yoshio Kazuno, MDe,
- Nobuyuki Takahashi, MDe,
- Richard Olson, BSME, MBAc,
- Joe Alkhatib, BSMEc,
- Daniel Berman, MDe,
- John Friedman, MDe,
- Norman Gellada, RT, CRTe,
- Tarun Chakravarty, MDe and
- Raj R. Makkar, MDe
- aHeart Valve Center, New York University Langone Medical Center, New York, New York
- bMedStar Cardiovascular Research Network at Washington Hospital Center, Washington DC
- cSt. Jude Medical, Minnepolis, Minnesota
- dHackensack University Medical Center, Hackensack, New Jersey
- eCedars-Sinai Heart Institute, Los Angeles, California
- ↵∗Address for correspondence:
Dr. Hasan Jilaihawi, Heart Valve Center, NYU Langone Medical Center, 530 1st Avenue, Suite 9V, New York, New York 10016.
Subclinical leaflet thrombosis was recently described in a randomized trial of transcatheter aortic valve replacement. It was subsequently demonstrated in a series of registries that this was a commonly observed imaging finding seen in all transcatheter and surgical bioprostheses. The phenomenon has aroused considerable interest due to the as-yet-undefined risk for later clinical events and the possibility of pharmacological intervention with anticoagulation. Subclinical leaflet thrombosis is easily detected noninvasively by technically suitable computed tomography (CT) with a high degree of concordance to transesophageal echocardiography findings. The CT hallmarks were noted to be hypoattenuated leaflet thickening (HALT) associated with reduced leaflet motion (RELM). The combination of HALT and RELM signified hypoattenuation affecting motion, the standardized imaging endpoint used. This paper describes the systematic CT evaluation methodology that was devised during the Portico trial investigation and U.S. Food and Drug Administration submission; it also highlights the need for an ongoing discussion among experts to enable, with the help of the Valve Academic Research Consortium, standardization of reporting of this imaging finding to cater to the present and future needs of clinical trials.
- aortic stenosis
- aortic valve replacement
- leaflet thrombosis
- transcatheter aortic valve implantation
- transcatheter aortic valve replacement
Dr. Jilaihawi is a consultant for Edwards Lifesciences and Venus Medtech. Mr. Olson and Mr. Alkhatib are employees of Abbott Vascular. Dr. Makkar has received a research grant and consulting fees from Edwards LifeSciences; and a research grant from Medtronic and St. Jude Medical. Dr. Asch directs an academic Echo Core lab for the Portico IDE trial, through an institutional contract with St. Jude Medical. Dr. Manasse is VP Medical Affairs for Abbott Laboratories. Dr. Ruiz has received research grants from Philips. Dr. Jelnin has received research grants from Philips and St. Jude Medical; and has received an educational grant from Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 15, 2016.
- Revision received February 13, 2017.
- Accepted February 17, 2017.
- 2017 American College of Cardiology Foundation
- Central Illustration
- CT Appearance of Hypoattenuated Leaflet Thickening
- CT Assessment of Reduced Leaflet Motion and Hypoattenuation Affecting Motion
- CT Acquisition Protocols
- Technical Considerations for CT Scan Interpretation
- CT Analysis Software and Protocols
- Leaflet Thickness/Thrombus Burden
- TAVR-Specific Analyses
- Commissural/Leaflet Orientation
- Stent Frame, Depth, and Symmetry of Implantation
- Potential Mechanisms of Subclinical Leaflet Thrombosis and the Value of Multimodal Imaging
- Potential for Clinical Sequelae of Subclinical Imaging Finding