Author + information
- Received August 23, 2016
- Revision received November 14, 2016
- Accepted November 16, 2016
- Published online January 2, 2017.
- Fernanda M. Mangione, MDa,
- Tannas Jatene, MDa,
- Alexandra Gonçalves, MD, PhD, MMSca,
- Gregory A. Fishbein, MDb,
- Richard N. Mitchell, MD, PhDb,
- Marc P. Pelletier, MDc,
- Tsuyoshi Kaneko, MDc,
- Pinak B. Shah, MDa,
- Charles B. Nyman, MBBChd,
- Douglas Shook, MDd,
- Ron Blankstein, MDa,
- Robert F. Padera, MD, PhDb and
- Deepak L. Bhatt, MD, MPHa,∗ ()
- aBrigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
- bBrigham and Women’s Hospital Department of Pathology and Harvard Medical School, Boston, Massachusetts
- cBrigham and Women’s Hospital Department of Surgery and Harvard Medical School, Boston, Massachusetts
- dBrigham and Women’s Hospital Department of Anesthesiology and Harvard Medical School, Boston, Massachusetts
- ↵∗Reprint requests and correspondence:
Dr. Deepak L. Bhatt, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115.
Leaflet thrombosis is currently one of the greatest concerns related to transcatheter aortic valve replacement (TAVR). Symptomatic valve thrombosis is a rare occurrence, but reduced leaflet motion, diagnosed by computed tomography, seems to be a more common finding (1).
We screened our pathology registries for patients with a prior TAVR who underwent a post-mortem examination or who had a TAVR device surgically explanted in an attempt to understand better the causes of TAVR failure. Of 13 valves studied, we found 4 cases of leaflet thrombosis diagnosed only on pathological examination (Figures 1, 2, 3, and 4, Online Videos 1, 2, and 3). Two of the patients had a valve-in-valve TAVR (Figures 1 and 3), and in 3 cases, there was incomplete expansion or asymmetry of the valve (Figures 1, 2, and 4). None of the patients were on anticoagulation. There were also 2 cases of endocarditis, 1 coronary obstruction, and 2 cases of paravalvular leak. The other 4 patients had no substantial valve findings.
TAVR valve thrombosis is underdiagnosed, and the mechanisms for its development might be associated with underexpansion and asymmetry of the valve. Valve-in-valve TAVR may be associated with these features more often and might be a risk factor for leaflet thrombosis.
For supplemental videos, please see the online version of this article.
Dr. Gonçalves has received funds from the Portuguese Foundation for Science and Technology, Grant HMSP-ICS/007/2012. Dr. Pelletier is a consultant for St. Jude Medical. Dr. Kaneko is a consultant for Edwards Lifesciences. Dr. Shah is a proctor for Edwards Lifesciences; and a course director for Edwards Lifesciences and St. Jude Medical. Dr. Nyman has received educational honoraria and holds stock in Edwards Lifesciences. Dr. Shook has received education honoraria from Edwards Lifesciences, Sorin Group, and Boston Scientific; and is a consultant for Edwards Lifesciences. Dr. Padera is a pathology consultant for Medtronic, Direct Flow, and Boston Scientific. Dr. Bhatt is on the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; is on the board of directors of Boston VA Research Institute and the Society of Cardiovascular Patient Care; chairs the American Heart Association Quality Oversight Committee; is on data monitoring committees for Duke Clinical Research Institute, Harvard Clinical Research Institute (including for his role as DMC Chair of the PORTICO trial), Mayo Clinic, and the Population Health Research Institute; has received honoraria from the American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; associate editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), and WebMD (CME steering committees); has other relationships with Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Vice-Chair), and VA CART Research and Publications Committee (Chair); has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; has received royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); has been a site coinvestigator for Biotronik, Boston Scientific, and St. Jude Medical; is a trustee of the American College of Cardiology; and has performed unfunded research for FlowCo, PLx Pharma, and Takeda. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 23, 2016.
- Revision received November 14, 2016.
- Accepted November 16, 2016.
- American College of Cardiology Foundation