Abstract
Introduction The TAVR procedure is associated with a substantial risk of thrombosis. Current guidelines recommend catheter-based aortic valve implantation for prohibitive-high-risk patients with severe aortic valve stenosis but acknowledge that the aetiology and mechanism of thrombosis are unclear. Methods From 2015 to 2018, 607 patients with severe aortic valve stenosis underwent either self-expandable or balloon-expandable catheter-based aortic valve implantation at our institute. A complementary study was designed to support computed tomography as a predictor of complications using an advanced biomodelling process through finite element analysis (FEA). The primary evaluation of study was the thrombosis of the valve at 12 months. Results At 12 months, 546 patients had normal valvular function. 61 patients had THVT while 6 showed thrombosis and dislodgement with deterioration to NYHA Class IV requiring rehospitalization. The FEA biomodelling revealed a strong link between solid uncrushed calcifications, delayed dislodgement of TAVR and late thrombosis. We observed an interesting phenomenon of fibrosis/calcification originating at the level of the misplaced valve, which was the primary cause of coronary obstruction. Conclusion The use of cardiac CT and predictive biomodelling should be integrated into routine practice for the selection of TAVR candidates and as a predictor of negative outcomes given the lack of accurate investigations available. This would assist in effective decision-making and diagnosis especially in a high-risk cohort of patients.
Highlights
The Transcatheter Aortic Valve Replacement (TAVR) procedure is associated with a substantial risk of thrombosis
We studied patients with severe aortic valve stenosis who underwent either self-expandable or balloon-expandable catheter-based valve replacement
The authors noted that the risk of transcatheter heart valve (THV) thrombosis in patients who did not receive anticoagulant treatment was higher compared to patients who received warfarin (10.7% versus 1.8%; risk ratio [RR]: 6.09; 95% confidence interval [CI]: 1.86 to 19.84) and larger sized self-expandable transcatheter aortic valves (≥29mm) had an increased incidence of THV thrombosis (p = 0.03)
Summary
The TAVR procedure is associated with a substantial risk of thrombosis. Current guidelines recommend catheterbased aortic valve implantation for prohibitive-high-risk patients with severe aortic valve stenosis but acknowledge that the aetiology and mechanism of thrombosis are unclear. The use of cardiac CT and predictive biomodelling should be integrated into routine practice for the selection of TAVR candidates and as a predictor of negative outcomes given the lack of accurate investigations available. This would assist in effective decision-making and diagnosis especially in a high-risk cohort of patients. Freedom from oral anticoagulation related complications and excellent quality of life support the use of biological materials [24,25,26,27,28,29] These benefits are less demonstrable when the most articulated armamentarium of TAVR is implanted in the aortic root. As a matter of fact, two fundamental obstacles could obscure the debate on the extensive indication of TAVR proposed in the guidelines: thrombosis of catheter-based
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