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JACC Case Rep
JACC Case Rep
JACC Case Reports
2666-0849
Elsevier

S2666-0849(24)00248-1
10.1016/j.jaccas.2024.102455
102455
Valvular Heart Disease
Case Report: Clinical Case
What Is the Optimal Antithrombotic Therapy for Valsalva Thrombus Following Transcatheter Aortic Valve Replacement?
Kato Yuta MD, PhD y.katoh0119@gmail.com
a∗
Kawahira Yuto MD, PhD a
Miyazaki Midori MD b
Hirata Tetsuo MD a
Kuwahara Go MD, PhD c
Sugihara Makoto MD, PhD a
Miura Shinichiro MD, PhD a
a Department of Cardiology, Fukuoka University Hospital, Fukuoka, Japan
b Department of Clinical Laboratory and Transfusion, Fukuoka University Hospital, Fukuoka, Japan
c Department of Cardiovascular Surgery, Fukuoka University Hospital, Fukuoka, Japan
∗ Address for correspondence: Dr Yuta Kato, Department of Cardiology, Fukuoka University School of Medicine, 7-45-1 Nanakuma, Jyonan-ku, Fukuoka 814-0180, Japan. y.katoh0119@gmail.com
21 8 2024
21 8 2024
21 8 2024
29 16 1024555 3 2024
9 5 2024
20 5 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Thrombus formation between the native sinus of Valsalva and the implanted transcatheter heart valve is a rare complication that may be associated with an increased risk for thrombotic complications. This paper presents the course of 3 cases with Valsalva thrombus, with a focus on the management of antithrombotic therapy.

Graphical Abstract

Key Words

antithrombotic therapy
transcatheter aortic valve replacement
Valsalva thrombus
Abbreviations and Acronyms

AS aortic stenosis

CMA commissural misalignment

HALT hypoattenuating leaflet thickening

MDCT multidetector computed tomography

NCC noncoronary cusp

OAC oral anticoagulation

PVL perivalvular leakage

RCC right coronary cusp

SAPT single-antiplatelet therapy

SEV self-expanding valve

SOV sinus of Valsalva

STJ sinotubular junction

TAVR transcatheter aortic valve replacement

THV transcatheter heart valve

VT Valsalva thrombus
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pmcTranscatheter aortic valve replacement (TAVR) is an established treatment for severe aortic stenosis (AS), and has been extended for use in low surgical risk patients with a successful midterm outcome.1 Hypoattenuating leaflet thickening (HALT) is one of the complications after TAVR. Many studies have indicated that HALT was not associated with mortality or cerebrovascular events; however, the impact of HALT on structural valve deterioration has been suggested, raising concerns about the clinical implications of HALT.2 In a meta-analysis, oral anticoagulation (OAC) reduced a relative risk for HALT compared with single-antiplatelet therapy (SAPT), and switch from SAPT to OAC led to resolution of HALT.3Learning Objectives

• To recognize Valsalva thrombus as one of the complications after TAVR.

• To describe the difference in clinical course between antiplatelet therapy and anticoagulation therapy for Valsalva thrombus.

• To understand the importance of early anticoagulation when observing this complication.

Thrombus formation between the native sinus of Valsalva (SOV) and the implanted transcatheter heart valve (THV), although rare, has been reported as one of the thrombotic complications after TAVR.4 The management of antithrombotic therapy for Valsalva thrombus (VT) after TAVR remains not elucidated.

Here we present a series of 3 patients presenting with VT after TAVR using self-expanding valve (SEV).

Case 1

An 83-year-old man was hospitalized for heart failure with very severe AS. Preprocedural multidetector computed tomography (MDCT) revealed type 1 bicuspid aortic valve (fusion of the right coronary cusp [RCC] and noncoronary cusp [NCC]) with severe calcification (Figure 1A), with an aortic annulus perimeter of 78 mm, SoV of 35 mm, and sinotubular junction (STJ) of 31 mm. After heart team review, transfemoral TAVR with an SEV was planned. After predilatation with a 22-mm balloon, a 29-mm Evolut PRO+ (Medtronic) was implanted. Final aortography showed no residual perivalvular leakage (PVL). A MDCT was performed to confirm the alignment of the THV and procedure complications 5 days after TAVR. The MDCT showed mild commissural misalignment (CMA) and a thrombus between the native NCC and the THV (Figures 1B and 1C). The patient received SAPT with clopidogrel after TAVR. Given the presence of VT, OAC with edoxaban was started, and SAPT was stopped. A 1-month MDCT was performed and showed a resolution of VT (Figure 1D).Figure 1 Preprocedural and Postprocedural Multidetector Computed Tomography

(A to D) Case 1. (E to I) Case 2. (J to R) Case 3. Preprocedural multidetector computed tomography (MDCT) (A, E, and J). Native-to-prosthetic commissural misalignment (B, F, and K) and Valsalva thrombus (C, G, and L) on 5-day MDCT after transcatheter aortic valve replacement. One-month (D, H, M, N, and O) and 2-month (I, P, Q, and R) MDCT after transcatheter aortic valve replacement. Yellow arrows point to the thrombus. Red, blue, and green arrows indicate each commissure of the transcatheter heart valve. Black arrows show the direction of the RCA. ∗Right coronary artery. LCC = left coronary cusp; NCC = noncoronary cusp; RCA = right coronary artery; RCC = right coronary cusp.

Case 2

The patient was a 74-year-old woman with symptomatic very severe AS. Preprocedural MDCT revealed tricuspid aortic valve with severe calcification in the NCC (Figure 1E), with an annulus perimeter of 69 mm and narrow aortic root (average SoV: 27 mm, average STJ: 21 mm). After discussion in our heart team, a decision of transfemoral TAVR using an SEV was recommended based on the intermediate surgical risk, frailty, and a small aortic annulus. After balloon aortic valvuloplasty with a 20-mm balloon catheter, a 26-mm Evolut PRO+ was implanted. We performed postdilatation with a 20-mm balloon catheter, resulting in mild PVL in the final aortography. The patient started to receive SAPT with aspirin after TAVR. A 5-day MDCT revealed severe CMA and VT in the NCC (Figures 1F and 1G); however, SAPT was continued. A 1-month MDCT showed that VT in the NCC remained (Figure 1H). Therefore, she was switched from SAPT to OAC with edoxaban. However, VT had not resolved on 2-month MDCT (Figure 1I).

Case 3

An 83-year-old man with symptomatic severe AS was referred for TAVR. He had a history of previous ischemic stroke and lung cancer treated with radiotherapy 2 months prior. Thus, he was receiving SAPT with clopidogrel. Preprocedural MDCT confirmed tricuspid aortic valve with mild calcification (Figure 1J), with an aortic annulus perimeter of 80 mm, SoV of 33 mm, and STJ of 28 mm. Our heart team decided that he was a candidate for TAVR based on his background. After balloon aortic valvuloplasty with a 22-mm balloon catheter, a 29-mm Evolut FX (Medtronic) was successfully implanted on the second attempt (1 recapture). Final aortography showed no residual PVL, with dense contrast agent stagnation at the NCC (Video 1). Although VT was identified in the NCC on a 5-day MDCT (Figure 1L), SAPT was continued. Surprisingly, VT were identified in not only the NCC but also the RCC on a 1-month MDCT (Figures 1M to 1O). VT on the RCC appeared to infiltrate into the right coronary artery (Figure 1N). Given the computed tomography findings, he was switched from SAPT to OAC with edoxaban. On 2-month MDCT, VT on the RCC had resolved, whereas VT on the NCC remained persistent (Figures 1P to 1R).

Discussion

VT after TAVR is a rare phenomenon potentially leading to thromboembolic events. Previous studies indicated that VT was found in 4% to 8.9% of the patients who had underwent TAVR, and identified early phase after TAVR compared with HALT (6 vs 389 days).5,6 Several considerations have been discussed about the etiologies for thrombosis after TAVR: these involve the TAVR procedure, THV geometry, blood stasis, and antithrombotic therapy. Of these, the causes of blood stasis include the blood stagnation within the sinus and neosinus, a narrow or low STJ, the large SOV, and native-to-prosthetic CMA. Moreover, the higher incidence of thrombosis in the NCC is attributed to the absence of sinus washout by coronary flow. Consequently, sinus contrast material retention in the aortogram after TAVR,7 and the area of the Valsalva to THV ratio,5 were reported as predictive factors for VT.

In our report, no thromboembolic events were observed, and echocardiography revealed preserved prosthetic valve function during the follow-up period in all cases. VT was located in the NCC and identified within 5 days after TAVR in all cases. The STJ was smaller than the THV size in 2 cases, whereas the SOV was not large in all cases (Table 1). Note that case 2 had both severe CMA and coronary misalignment, whereas case 3 had contrast stagnation and moderate coronary misalignment without CMA.Table 1 Differences of Characteristics and Management of Antithrombotic Therapy for VT

	Case 1	Case 2	Case 3	
Age, y	83	74	83	
Sex	Male	Female	Male	
Society of Thoracic Surgeons risk score, %	3.3	5.0	3.1	
Annulus perimeter, mm	78	69	80	
Sinus of Valsalva, mm	35	27	33	
Sinotubular junction, mm	31	21	28	
Valve size, mm	29	26	29	
Perivalvular leakage	None	Mild	None	
Contrast stagnation	None	None	NCC	
Commissural misalignment	Mild	Severe	None (aligned)	
Coronary misalignment	None (aligned)	Severe	Moderate	
Antithrombotic therapy after TAVR	SAPT	SAPT	SAPT	
Antithrombotic therapy 1-week after TAVR	OAC	SAPT	SAPT	
Antithrombotic therapy 1-month after TAVR	OAC	OAC	OAC	
VT formation on 5-day CT	NCC	NCC	NCC	
VT formation on 1-month CT	Resolved	NCC remained	NCC plus RCC	
VT formation on 2-month CT	N/A	NCC remained	NCC: remained, RCC: resolved	
Others	Bicuspid	Postdilatation	Cancer, stroke	
CT = computed tomography; N/A = not available; NCC = noncoronary cusp; OAC = oral anticoagulation; RCC = right-coronary cusp; SAPT = single-antiplatelet therapy; TAVR = transcatheter aortic valve replacement; VT = Valsalva thrombus.

SAPT has become the preferred antithrombotic therapy after TAVR in patients without an indication for OAC, whereas OAC has been associated with decreased risk for HALT. On the other hand, the management of antithrombotic therapy for VT remains unclear. Couture et al4 reported a stroke case due to VT in a patient with bicuspid aortic valve who was treated with warfarin. In that case, switching from aspirin to OAC was effective for VT resolution. We presented that switching to OAC within 1 week after TAVR was effective for the resolution of VT; however, it was not effective over 30 days after TAVR. Although the clinical implications of VT remain uncertain, the deferring of switching to OAC may result in its progression. On the contrary, Sondergaard et al8 reported that HALT can develop and regress at variable intervals after TAVR regardless of antithrombotic therapy, and maintenance on chronic OAC did not lead to regression of HALT. Further studies are needed to investigate whether screening/follow-up MDCT and appropriate antithrombotic therapy (regimens and period) for VT influence the THV function and clinical events.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Case 3 Final Aortography

Contrast agent retention in the noncoronary sinus after transcatheter heart valve implantation.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Appendix

For supplemental videos, please see the online version of this paper.
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