title: Transcatheter aortic valve thrombosis: the relation between hypo-attenuated leaflet thickening, abnormal valve haemodynamics, and stroke.
abstract: OBJECTIVE
  The presence of hypo-attenuated leaflet thickening (HALT) and/or reduced leaflet motion on multi-detector row computed tomography (MDCT) has been proposed as a possible marker for early transcatheter aortic valve thrombosis. However, its association with abnormal valve haemodynamics on echocardiography (another potential marker of thrombosis) and clinical outcomes (stroke) remains unclear. The present study evaluated the prevalence of HALT on MDCT and abnormal valve haemodynamics on echocardiography. In addition, the occurrence of ischemic stroke and/or transient ischemic attack (TIA) was assessed.
  
  
  RESULTS
  A total of 434 patients (mean age 80 ± 7 years, 51% male) who underwent transcatheter aortic valve replacement (TAVR) were evaluated. Transcatheter valve haemodynamics were assessed on echocardiography at discharge, 6 months, and thereafter yearly (up to 3 years post-TAVR). The presence of HALT and/or reduced leaflet motion was assessed on MDCT performed 35 days [interquartile range 19-210] after TAVR in 128 of these 434 patients. Possible TAVR valve thrombosis was defined by mean transvalvular gradient ≥20 mmHg and aortic valve area (AVA) ≤1.1cm2 on echocardiography or by the presence of HALT or reduced leaflet motion on MDCT. The occurrence of ischemic stroke/TIA at follow-up was recorded. HALT and/or reduced leaflet motion was present in 12.5% of 128 patients undergoing MDCT, and was associated with a slightly higher mean transvalvular gradient (12.4 ± 8.0 mmHg vs. 9.4 ± 4.3 mmHg; P = 0.026) and smaller AVA (1.49 ± 0.39 cm2 vs. 1.78 ± 0.45 cm2, P = 0.017). Only one patient with HALT on MDCT revealed abnormal valve haemodynamics on echocardiography. At 3-year follow-up, abnormal valve haemodynamics on echocardiography were observed in 3% of patients. HALT on MDCT and abnormal valve haemodynamics on echocardiography were not associated with increased risk of ischemic stroke/TIA.
  
  
  CONCLUSIONS
  On MDCT, 12.5% of patients showed HALT or reduced leaflet motion, whereas only one of these patients had abnormal valve haemodynamics on echocardiography. Neither HALT nor increased transvalvular gradient were associated with stroke/TIA.
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: E Mara
authors.initials: EM
authors.lastname: Vollema
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.|Department of Cardiology, National University Heart Centre, Singapore.
authors.forename: William K F
authors.initials: WKF
authors.lastname: Kong
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.|National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece.
authors.forename: Spyridon
authors.initials: S
authors.lastname: Katsanos
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.|Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece.
authors.forename: Vasileios
authors.initials: V
authors.lastname: Kamperidis
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Philippe J
authors.initials: PJ
authors.lastname: van Rosendael
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Frank
authors.initials: F
authors.lastname: van der Kley
authors.affiliation: Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Arend
authors.initials: A
authors.lastname: de Weger
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Nina
authors.initials: N
authors.lastname: Ajmone Marsan
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Victoria
authors.initials: V
authors.lastname: Delgado
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Jeroen J
authors.initials: JJ
authors.lastname: Bax
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000601:surgery; D005260:Female; D006349:Heart Valve Diseases / Q000209:etiology / Q000503:physiopathology*; D006350:Heart Valve Prosthesis; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D061330:Multidetector Computed Tomography; D011446:Prospective Studies; D020521:Stroke / Q000209:etiology* / Q000503:physiopathology; D013927:Thrombosis / Q000209:etiology / Q000503:physiopathology*; D065467:Transcatheter Aortic Valve Replacement; D016896:Treatment Outcome
keywords: Echocardiography; Multi-detector row computed tomography ; Stroke; Thrombosis; Transcatheter aortic valve replacement