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

S2666-0849(24)00238-9
10.1016/j.jaccas.2024.102445
102445
Valvular Heart Disease
Editorial Comment
Should Routine CT Follow-Up Be Considered After TAVR?
Fukui Miho MD, PhD miho.fukui@allina.com
a∗
Sorajja Paul MD bc
a Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
b Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
c Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
∗ Address for correspondence: Dr Miho Fukui, Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 740, Minneapolis, Minnesota 55407, USA. miho.fukui@allina.com
21 8 2024
21 8 2024
21 8 2024
29 16 102445© 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/).
Corresponding Author

Key Words

cardiac CT
HALT
sinus of valsalva
TAVI
thrombosis
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pmcOn cardiac computed tomography (CT) images post–transcatheter aortic valve replacement (TAVR) implantation, hypoattenuating effects are occasionally observed on the transcatheter aortic valve (TAV) prosthesis leaflets and/or the native sinus between the aortic sinus and the native aortic valve leaflets or TAV stent frame (Figure 1). The former is known as hypoattenuating leaflet thickening (HALT), which is a subclinical CT finding, or as valve thrombosis when accompanied by symptoms or significant valve dysfunction. The latter is termed as Valsalva thrombus.Figure 1 HALT and Valsalva Thrombosis

Hypoattenuating effects are occasionally observed on the transcatheter aortic valve prosthesis leaflets, known as hypoattenuating leaflet thickening (HALT) or valve thrombosis, and/or the native sinus between the aortic sinus and the native aortic valve leaflets or transcatheter aortic valve stent frame, known as Valsalva thrombus.

In this issue of JACC: Case Reports, Kato et al1 demonstrate that Valsalva thrombus is potentially treatable with anticoagulation therapy. Although data are limited and its definition is not yet clearly established, Valsalva thrombosis is not uncommon, with reported incidences ranging from 9% to 32% following TAVR.2,3 It predominantly occurs in the noncoronary cusp, rather than in the right coronary artery or left coronary artery cusps due to lower washout flow in the noncoronary cusp.1 Valsalva thrombosis may or may not be associated with HALT, but both are easily detected on routine cardiac CT post-TAVR. An important distinguishing feature is that Valsalva thrombosis does not involve the TAV prosthesis leaflets and thus is not expected to affect the long-term durability of the TAV. While HALT has been broadly investigated, our understanding of Valsalva thrombosis is limited in terms of its clinical implications.

In light of these considerations, the question of routine CT follow-up in patients who have TAVR, or, for any matter, surgical aortic valve replacement, becomes increasingly pertinent. Given the limited and inconclusive evidence regarding the clinical impact of HALT or Valsalva thrombosis, currently proactive routine cardiac CT for patients after TAVR cannot be recommended broadly. Nevertheless, in 2015, we implemented a policy at our institution that requires prospective CT for all TAVR patients able to undergo repeat scanning (eg, no or low risk of contrast nephropathy). Our goals were to determine incidence and, in appropriate cases of HALT or thrombosis detection, manage patients with oral anticoagulation.3 Imaging substudies from pivotal clinical trials of TAVR have shown that oral anticoagulation can reduce the incidence of HALT. While it has not been shown to affect clinical outcomes, including mortality and thrombotic events, there is the possibility of positively affecting long-term durability.4,5 This issue is exceedingly important for patients with an expected longevity, in which avoiding TAV degeneration and potential reintervention is crucial, or for those at high risk of embolic events, proactive CT screening and therapeutic intervention may be valuable even in the absence of symptoms or echocardiographic changes. Prior histological studies have shown that thrombosis could occur just after TAV implantation and transform into fibrosis within a few months and eventually calcify over the years.6 Missing the appropriate treatment window may render HALT and Valsalva thrombosis irreversible, potentially impacting transcatheter heart valve durability. This is especially a concern when there is TAV deformation postimplantation.3 Excessive stent frame deformation could increase leaflet shear stress and affect the hemodynamics around the valve, potentially leading to an increased risk of thrombosis and degeneration. In such cases, vigilant CT screening after the procedure could be considered.

At this point, these strategies for proactive follow-up and pharmacological intervention should always be tailored to the individual patient's context, carefully weighing the risks and benefits in terms of lifetime management. Generalization for routine follow-up CT and antithrombotic therapy after TAVR requires further longitudinal data accumulation, especially in low-risk patients with longer life expectancies. Because Valsalva thrombosis and HALT are typically subclinical, prospective CT registries and evaluations in consecutive patients are required to fully understand their incidence and clinical implications.

Funding Support and Author Disclosures

Dr Fukui has served as a consultant for Edwards Lifesciences. Dr Sorajja has served as consultant for 4C Medical, Abbott Structural, Adona Shifamed, Boston Scientific, Foldax, GE Medical, Haemonetics, Laza, Medtronic, Philipps, xDot, and VDyne.

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.
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References

1 Kato Y. Kawahira Y. Miyazaki M. What is the optimal antithrombotic therapy for Valsalva thrombus following transcatheter aortic valve replacement? JACC Case Rep 29 2024 102455
2 Tsunaki T. Yamamoto M. Shimura T. Silent Valsalva thrombus between the native Valsalva and balloon-expandable transcatheter heart valve: multicentre Japanese registry analysis EuroIntervention 15 10 2019 892 899 10.4244/EIJ-D-19-00370 31746754
3 Fukui M. Bapat V.N. Garcia S. Deformation of transcatheter aortic valve prostheses: implications for hypoattenuating leaflet thickening and clinical outcomes Circulation 146 6 2022 480 493 10.1161/CIRCULATIONAHA.121.058339 35862182
4 De Backer O. Dangas G.D. Jilaihawi H. Reduced leaflet motion after transcatheter aortic-valve replacement N Engl J Med 382 2 2020 130 139 10.1056/NEJMoa1911426 31733182
5 Montalescot G. Redheuil A. Vincent F. Apixaban and valve thrombosis after transcatheter aortic valve replacement: the ATLANTIS-4D-CT randomized clinical trial substudy JACC Cardiovasc Interv 15 18 2022 1794 1804 10.1016/j.jcin.2022.07.014 36137682
6 Sellers S.L. Turner C.T. Sathananthan J. Transcatheter aortic heart valves: histological analysis providing insight to leaflet thickening and structural valve degeneration JACC Cardiovasc Imaging 12 1 2019 135 145 10.1016/j.jcmg.2018.06.028 30448122
