title: Course of early subclinical leaflet thrombosis after transcatheter aortic valve implantation with or without oral anticoagulation.
abstract: BACKGROUND
  After transcatheter aortic valve implantation, early leaflet thickening, presumably reflecting thrombus, has recently been described on computed tomography angiography (CTA) in ~10% of the patients. We sought to investigate the impact of the antithrombotic regimen on the course of leaflet thickening.
  
  
  METHODS
  The study comprised 51 patients with leaflet thickening. Based on the time period, patients without an established indication for anticoagulation were put on phenprocoumon plus clopidogrel for at least 3 months or on dual antiplatelet therapy with aspirin and clopidogrel. Follow-up CTAs were evaluated for leaflet restriction, assessed by four-point-grading score, and maximal thickness.
  
  
  RESULTS
  The anticoagulation and the dual antiplatelet therapy group comprised 29 and 22 patients, respectively. After a median of 86 days, we obtained follow-up CTAs in 22 patients on anticoagulation and in 16 patients on dual antiplatelet therapy. Leaflet thickening progressed in 11 on dual antiplatelet therapy, but always regressed onanticoagulation. The course of leaflet restriction and maximal thickness was significantly different between the two groups (P < 0.001): in the dual antiplatelet therapy group, maximal thickness increased by a mean of 1.37 ± 1.67 mm (P = 0.005) and leaflet restriction score by a median 1[quartiles 0;2] (P = 0.013), whereas in the anticoagulation group, maximal thickness regressed by 2.57 ± 1.52 mm (P < 0.001) and leaflet restriction score decreased by 1[-4;0] (P = 0.001). After a median of 91 days after discontinuation of anticoagulation, CTA performed in ten patients revealed a significant recurrent increase in leaflet restriction score and maximal thickness (P = 0.023, P = 0.007). In the entire cohort, changes in leaflet restriction correlated significantly with changes in transvalvular pressure gradients (r = 0.511, P < 0.001).
  
  
  CONCLUSIONS
  The course of leaflet restriction was fundamentally different depending on the presence or absence of anticoagulation, with consistent regression under phenprocoumon, but mostly progression under antiplatelet therapy alone. Changes in leaflet restriction were associated with changes in transvalvular pressure gradients.
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany. philipp.ruile@universitaets-herzzentrum.de.
authors.forename: Philipp
authors.initials: P
authors.lastname: Ruile
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Jander
authors.affiliation: Center for Heart Valve Innovation, St. Paul's Hospital and University of British Columbia, Vancouver, Canada.
authors.forename: Philipp
authors.initials: P
authors.lastname: Blanke
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
authors.forename: Simon
authors.initials: S
authors.lastname: Schoechlin
authors.affiliation: Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
authors.forename: Jochen
authors.initials: J
authors.lastname: Reinöhl
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Gick
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
authors.forename: Juergen
authors.initials: J
authors.lastname: Rothe
authors.affiliation: Department of Radiology, Section of Cardiovascular Radiology, University of Freiburg, Freiburg im Breisgau, Germany.
authors.forename: Mathias
authors.initials: M
authors.lastname: Langer
authors.affiliation: Center for Heart Valve Innovation, St. Paul's Hospital and University of British Columbia, Vancouver, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
authors.forename: Heinz-Joachim
authors.initials: HJ
authors.lastname: Buettner
authors.affiliation: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
authors.forename: Franz-Josef
authors.initials: FJ
authors.lastname: Neumann
authors.affiliation: Department of Radiology, Section of Cardiovascular Radiology, University of Freiburg, Freiburg im Breisgau, Germany.
authors.forename: Gregor
authors.initials: G
authors.lastname: Pache
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage*; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000187:drug effects* / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D004334:Drug Administration Schedule; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006439:Hemodynamics; D006801:Humans; D008297:Male; D010644:Phenprocoumon / Q000008:administration & dosage*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D013927:Thrombosis / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D010644:Phenprocoumon
keywords: Aortic stenosis; CTA; Leaflet thickening; TAVI; TAVR; Thrombosis