Transcatheter Heart Valve Thrombosis Research Articles

Altered blood flow due to larger aortic diameters in patients with transcatheter heart valve thrombosis.

The etiology of transcatheter heart valve thrombosis (THVT) and the relevance of the aortic root geometry on the occurrence of THVT are largely unknown. The first aim of this pilot study is to identify differences in aortic root geometry between THVT patients and patients without THVT after transcatheter aortic valve implantation (TAVI). Second, we aim to investigate how the observed difference in aortic diameters affects the aortic flow using idealized computational geometric models. Aortic dimension was assessed using pre-TAVI multi-detector computed tomography scans of eight patients with clinical apparent THVT and 16 unaffected patients (two for each THVT patient with same valve type and size) from the Bern-TAVI registry. Among patients with THVT the right coronary artery height was lower (-40%), and sinotubular junction (STJ) and ascending aorta (AAo) diameters tended to be larger (9% and 14%, respectively) compared to the unaffected patients. Fluid-structure interaction (FSI) in two idealized aortic models with the observed differences in STJ and AAo diameter showed higher backflow rate at the STJ (+16%), lower velocity magnitudes in the sinus (-5%), and higher systolic turbulent dissipation rate in the AAo (+8%) in the model with larger STJ and AAo diameters. This pilot study suggests a direct effect of the aortic dimensions on clinically apparent THVT. The FSI study indicates that larger STJ and AAo diameters potentially favor thrombus formation by increased backflow rate and reduced wash-out efficiency of the sinus. The reported observations require clinical validation but could potentially help identifying patients at risk for THVT.

Transcatheter heart valve thrombosis on the mitral stage: "The Tempest" or "Much Ado About Nothing"?

Transcatheter heart valve thrombosis on the mitral stage: "The Tempest" or "Much Ado About Nothing"?

Usefulness of Antiplatelet Therapy After Transcatheter Aortic Valve Implantation

The rationale for dual antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI) is to facilitate endothelialization of metallic struts of the transcatheter heart valve and to prevent thrombosis that could lead to thromboembolic events. Based on expert consensus, current societal guidelines recommend DAPT for 1 to 6 months after TAVI with weak evidence. Although the pivotal TAVI trials mandated this regimen, the evidence for the efficacy of DAPT to prevent transcatheter heart valve thrombosis is limited to 3 small trials and a handful of observational studies. Multiple coronary trials have demonstrated that DAPT is associated with increased bleeding in comparison with single antiplatelet therapy, especially in elderly patients. TAVI patients are predominantly elderly and frequently have risk factors that predispose them to bleeding. Herein, we summarize the evidence for antiplatelet therapy after TAVI and explore the theoretical benefit of DAPT to prevent thromboembolic events versus the risk of increased bleeding.

Transcatheter aortic valve thrombosis: Data from a French multicenter cohort analysis.

To evaluate the effectiveness of anticoagulant therapies in patients with clinical transcatheter heart valve (THV) thrombosis, to describe complications, and to assess their risk profile was the objectives. Little research has been conducted on clinical THV thrombosis. Patients with clinical THV thrombosis were identified based on greater than 50% increased transvalvular gradient on transthoracic echocardiogram confirmed by 4-dimensional computed tomography, transesophageal echocardiogram, or regression with anticoagulant therapy. A cohort free from thrombosis for more than 1,100 days postprocedure was used for comparison. Fifty-four patients with clinical THV thrombosis were identified. Most subjects (98.1%) received anticoagulant therapy which was effective (≥50% reduction in transvalvular gradient or return to postprocedure value) in 96%. The rate of serious hemodynamic or embolic complications in the thrombosis population was 31.5%. A multivariate analysis of subjects with and without thrombosis indicated a significantly increased risk of thrombosis from preexisting thrombocytopenia (odds ratio [OR] 9.96), absence of predilatation (OR=5.67), renal insufficiency (OR=4.84), and >10 mmHg mean transvalvular gradient postprocedure (OR=3.36). No recurrence of thrombosis was identified during on average 685 days follow-up. These data, from one of the largest cohorts with clinical THV thrombosis confirm anticoagulants appear effective. The rate of serious associated complications was high. The findings underline the importance of recognizing risk factors for thrombosis.

Valve thrombosis after transcatheter mitral valve implantation

Transcatheter mitral valve implantation (TMVI) is a new treatment option for high-risk surgical patients with degenerated bioprosthesis (ViV), failed annuloplasty rings (ViR) and severe mitral annular calcification (ViMAC). However, limited data exist on transcatheter heart valve (THV) thrombosis. To report the incidence, clinical impact and treatment outcomes of THV thrombosis in patients undergoing TMVI. All consecutive patients underwent TMVI in our center between July 2010 and September 2019 were included. A transoesophageal echocardiography (TOE) and a computed tomography (CT) were performed at discharge and each follow-up clinical visit (3 months, 1 year and then annually). THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion confirmed by TOE and/or contrast CT, and was classified according to the timing of diagnosis as immediate (at discharge), early (at the 3-month clinical visit), or late (at the 1-year clinical visit and thereafter) ( Table 1 ). A total of 132 patients underwent TMVI. At a median follow-up of 1.4 years, THV thrombosis was observed in 16 (12.1%) patients: 7 (43.8%) in the ViV TMVI group, 5 (31.2%) in the ViR group and 4 (25%) in the ViMAC group ( P = 0.93). In 13 (81.2%) patients, THV thrombosis occured within the first 3 months. Neither stroke nor other thromboembolic event occurred. Rates of early and late THV thrombosis were higher in patients without anticoagulation than in those treated with anticoagulation (respectively 25% vs.3.2%, p = 0.018 and 13.6% vs.0%, P = 0.023). After optimization of antithrombotic treatment, THV thrombosis resolved in all but one asymptomatic patient ( Fig. 1 ). THV thrombosis is frequent after TMVI, occurs mainly within the first 3 months, is mostly subclinical and resolves after optimization of antithrombotic treatment. An anticoagulation therapy for at least 3 months after the procedure is mandatory.

Predictors and clinical impact of thrombosis after transcatheter mitral valve implantation using balloon-expandable bioprostheses.

The aim of this study was to report the predictors and clinical impact of transcatheter heart valve (THV) thrombosis in patients undergoing transcatheter mitral valve implantation (TMVI). We included 130 patients who consecutively underwent TMVI. Transoesophageal echocardiography (TOE) and/or computed tomography (CT) were performed in 91.7% of patients at discharge, in 73.3% at three months and in 72% beyond three months. THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion confirmed by TOE or contrast CT and classified as immediate, early, or late according to the timing of diagnosis. THV thrombosis was observed in 16 (12.3%) patients: immediate in 43.7%, early in 37.5% and late in 18.8%. Most of these thromboses were subclinical (93.7%) and non-obstructive (87.5%). No thromboembolic event occurred. After optimisation of antithrombotic treatment, THV thromboses resolved in all but one patient. Predictors were shock for immediate (p<0.001), male sex for early (p=0.045) and absence of anticoagulation for both early (p=0.018) and late (p=0.023) THV thromboses. THV thrombosis is frequent after TMVI, occurs mainly within the first three months, is mostly subclinical and resolves after optimisation of antithrombotic treatment. An anticoagulation therapy for at least three months after the procedure is mandatory.

Abstract 17422: Transcatheter Mitral Valve Thrombosis: A Case Report and Literature Review

Background: Trans-catheter mitral valve replacement (TMVR) is an exciting alternative therapy for complex patients with mitral valve disease. The experience with TMVR is new and there is a lot yet to discover about their durability, long-term outcomes, and complications including, mitral transcatheter heart valve (THV) thrombosis. Many factors have been speculated to be associated with the increased risk of THV thrombosis. Here, we report a case of mitral THV thrombosis then discuss published data on the subject. Case presentation: A 72-year-old woman who underwent TMVR for severe mitral regurgitation with mitral annular calcification. She was discharged on aspirin and clopidogrel for thromboprophylaxis. She presented after 30 days with symptomatic heart failure. Her transesophageal echocardiogram showed increased mean trans-mitral gradient with severe subvalvular thickening with immobile neo-anterior leaflet. She was subsequently started on a heparin drip with bridge to warfarin with international normalized ratio goal of 2.5 to 3.5. Discussion: Since most patients undergoing TMVR are within a high-risk population, caution should be implemented to minimize complications, valve dysfunction, and failure. We reviewed 42 TMVR papers with total of 1484 patients including 60 with mitral THV thrombosis. We discussed the most common strategies used for mitral THV thromboprophylaxis and treatment. Conclusion: Given current evidence, post-TMVR anticoagulation should be considered for at least 3 months, especially in those without significant bleeding risk. Longer anti-coagulation therapy should be considered for patients with multiple risk factors for thrombus formation. Additionally, systematic active screening with close clinical follow up help promptly identify those with subclinical THV thrombosis or need longer anti-coagulation therapy.

Incidence, clinical impact and treatment outcomes of valve thrombosis after transcatheter mitral valve implantation

Abstract Background Transcatheter mitral valve implantation (TMVI) is a new treatment option for high-risk surgical patients with degenerated bioprosthesis (ViV), failed annuloplasty rings (ViR) and severe mitral annular calcification (ViMAC). However, limited data exist on transcatheter heart valve thrombosis. Purpose The aim of this study was to report the incidence, clinical impact and treatment outcomes of transcatheter heart valve (THV) thrombosis in patients undergoing TMVI. Methods All consecutive patients undergoing TMVI in our center between July 2010 and September 2019 were included. A transoesophageal echocardiography and a computed tomography (CT) were performed before hospital discharge and at each clinical visit, at 3 months, at 1 year and yearly after. THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion suggestive of thrombus confirmed by TOE and/or contrast CT. All patients received anticoagulation therapy with vitamin K antagonists (VKA) and a low dose of aspirin for the first 3 months. Results A total of 132 patients underwent TMVI (62 ViV, 36 ViR and 34 ViMAC). Among them, 16 (12.1%) patients had a THV thrombosis. Median age was 67 years old and 56.2% of patients were women. Median time to diagnosis of THV thrombosis was 78 days. Early THV thrombosis was observed in 7 (43.7%) and in 13 (81.2%) patients THV thrombosis occurred within the first 6 months after the procedure. 8 out 9 patients with subacute or late THV thrombosis were not anticoagulated or with subtherapeutic anticoagulation. No stroke or thromboembolic events occurred in these patients. No change in mitral gradient was observed in 14 out 16 patients. VKA were indicated in all patients. THV thrombosis resolved in all but one patient. Conclusion THV thrombosis is frequent after TMVI, occurs mainly within the first 6-months after the procedure, are mostly subclinical and resolves after optimization of anticoagulation treatment. An anticoagulation therapy for at least 6 months may be necessary. Timing of THV thrombosis Funding Acknowledgement Type of funding source: None

Leaflet immobility and thrombosis in transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has grown exponentially worldwide in the last decade. Due to the higher bleeding risks associated with oral anticoagulation and in patients undergoing TAVR, antiplatelet therapy is currently considered first-line antithrombotic treatment after TAVR. Recent studies suggest that some patients can develop subclinical transcatheter heart valve (THV) thrombosis after the procedure, whereby thrombus forms on the leaflets that can be a precursor to leaflet dysfunction. Compared with echocardiography, multidetector computed tomography is more sensitive at detecting THV thrombosis. Transcatheter heart valve thrombosis can occur while on dual antiplatelet therapy with aspirin and thienopyridine but significantly less with anticoagulation. This review summarizes the incidence and diagnostic criteria for THV thrombosis and discusses the pathophysiological mechanisms that may lead to thrombus formation, its natural history, potential clinical implications and treatment for these patients.

Bioprosthetic valve oversizing is associated with increased risk of valve thrombosis following TAVR.

Hypoattenuating leaflet thickening (HALT), the radiographic manifestation of transcatheter heart valve thrombosis, is commonly identified following transcatheter aortic valve replacement (TAVR) and associated with increased risk of stroke and structural valve deterioration. While anticoagulation effectively resolves HALT, routine use remains controversial. We aimed to identify hemodynamic, anatomic, and comorbid predictors of HALT. We evaluated consecutive patients with severe aortic stenosis who underwent TAVR with Edwards SAPIEN 3 bioprosthesis at a single center between June 1, 2018 and October 30, 2019. Patients on anticoagulation and those receiving valve-in-valve were excluded. Clinically driven computed tomography (CT) imaging was performed to assess for HALT at the discretion of the treating valve team. A total of 78 patients with a mean age of 78 ± 10 years and STS risk score 5.5 ± 3.3% were analyzed. HALT was identified in 11 (14.1%) patients. Compared to controls, those with HALT had smaller annular areas, 435 ± 57 mm2 vs. 489 ± 79 mm2 (p = .032), but received comparable size valves. In multivariate regression, valve oversizing by more than 20% was associated with increased risk of HALT, OR 23.5, 95% CI 2.5-223, (p = .006). After initiation of anticoagulation, patients with HALT had similar rates of stroke, major bleeding, and all-cause mortality out to an average of 243 days. In this pragmatic study of patients undergoing TAVR with SAPIEN 3 valves, we report the novel finding that oversizing by more than 20% was independently associated with increased risk of HALT. These findings warrant confirmation in larger and prospective trials.

Early results of the ongoing Polish Registry of Valve Thrombosis after Transcatheter Aortic Valve Implantation (ZAK‑POLTAVI).

Conflicting data exist regarding the risk factors for transcatheter heart valve thrombosis (THVT). In addition, no optimal pharmacological strategy to treat THVT has been established so far Aims: The aim of this study was to assess the incidence, risk factors, diagnostic workup, and treatment of THVT in Poland. Data were collected retrospectively in themulticenter registry of patients with THVT (ZAK‑POLTAVI) between November 2008 and November 2018. Transcatheter heart valve thrombosis was defined as an increased mean transvalvular gradient accompanied by a decreased effective orifice area or severe aortic regurgitation, reversible after treatment. Baseline characteristics and procedural data were compared between patients with THVT and those without THVT (matched by age, sex, and diabetic status). In a group of 2307 patients undergoing transcatheter aortic valve implantation (TAVI), 26 patients with THVT were identified (incidence, 1.14%). In half of the patients, THVT was diagnosed within 6 months after TAVI. As compared with the control group, patients with THVT more frequently had chronic obstructive pulmonary disease (P = 0.035), a smaller aortic valve area (P = 0.007), a higher mean postprocedural transvalvular gradient (P = 0.037), and a lower platelet count (P = 0.029) at the time of the diagnosis. A total of 24 patients (84.6%) received anticoagulation therapy for THVT, and complete resolution of THVT was noted in 12 individuals (46.1%). We observed thromboembolic complications in 2 patients (7.7%). Transcatheter heart valve thrombosis is a rare complication of TAVI. However, a higher risk of THVT may be expected in patients with chronic obstructive pulmonary disease, a smaller aortic valve area, a higher mean postprocedural transvalvular gradient, and a lower platelet count. Anticoagulation alone or combined with antiplatelet therapy seems to be the optimal pharmacological treatment in this population.

A Finite Element Analysis Study from 3D CT to Predict Transcatheter Heart Valve Thrombosis.

Background: Transcatheter aortic valve replacement has proved its safety and effectiveness in intermediate- to high-risk and inoperable patients with severe aortic stenosis. However, despite current guideline recommendations, the use of transcatheter aortic valve replacement (TAVR) to treat severe aortic valve stenosis caused by degenerative leaflet thickening and calcification has not been widely adopted in low-risk patients. This reluctance among both cardiac surgeons and cardiologists could be due to concerns regarding clinical and subclinical valve thrombosis. Stent performance alongside increased aortic root and leaflet stresses in surgical bioprostheses has been correlated with complications such as thrombosis, migration and structural valve degeneration. Materials and Methods: Self-expandable catheter-based aortic valve replacement (Medtronic, Minneapolis, MN, USA), which was received by patients who developed transcatheter heart valve thrombosis, was investigated using high-resolution biomodelling from computed tomography scanning. Calcific blocks were extracted from a 250 CT multi-slice image for precise three-dimensional geometry image reconstruction of the root and leaflets. Results: Distortion of the stent was observed with incomplete cranial and caudal expansion of the device. The incomplete deployment of the stent was evident in the presence of uncrushed refractory bulky calcifications. This resulted in incomplete alignment of the device within the aortic root and potential dislodgment. Conclusion: A Finite Element Analysis (FEA) investigation can anticipate the presence of calcified refractory blocks, the deformation of the prosthetic stent and the development of paravalvular orifice, and it may prevent subclinical and clinical TAVR thrombosis. Here we clearly demonstrate that using exact geometry from high-resolution CT scans in association with FEA allows detection of persistent bulky calcifications that may contribute to thrombus formation after TAVR procedure.

TRANSCATHETER MITRAL VALVE REPLACEMENT (TMVR) THROMBOSIS

TMVR has emerged as a therapeutic option for high-risk patients with severe mitral regurgitation (MR). Transcatheter heart valve (THV) thrombosis remains a clinical concern. A 81-year-old male with history of CAD, severe MR s/p TMVR (Intrepid) one-year ago presented with worsening shortness of

Clinical Valve Thrombosis and Subclinical Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Is There a Need for a Patient-Tailored Antithrombotic Therapy?

Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis at increased surgical risk. Antithrombotic therapy after TAVR aims to prevent transcatheter heart valve (THV) thrombosis, in which two different entities have to be recognized: clinical valve thrombosis and subclinical leaflet thrombosis. In clinical valve thrombosis, obstructive thrombus formation leads to an increased transvalvular gradient, often provoking heart failure symptoms. Subclinical leaflet thrombosis is most often an incidental finding, characterized by a thin layer of thrombus covering the aortic side of one or more leaflets; it is also referred to as Hypo-Attenuating Leaflet Thickening (HALT) as described on multi-detector computed tomography (MDCT) imaging. This phenomenon may also affect leaflet motion and is then classified as Hypo-Attenuation affecting Motion (HAM). Even in case of HAM, the transvalvular pressure gradient remains within normal range and does not provoke heart failure symptoms. Whereas, clinical valve thrombosis requires treatment, the clinical impact and need for intervention in subclinical leaflet thrombosis is still uncertain. Oral anticoagulant therapy protects against and resolves both clinical valve thrombosis and subclinical leaflet thrombosis; however, large-scale randomized clinical trials studying different antithrombotic strategies after TAVR are still under way. This review article summarizes the currently available data within the field of transcatheter aortic valve/leaflet thrombosis and discusses the need for a patient tailored antithrombotic approach.

How Can We Peri-procedurally Evaluate Transcatheter Heart Valve Thrombosis Risk?

Objectives: hrombosis in transcatheter heart valves (THVs) is of increasing clinical concern due to valve deterioration and thromboembolism risks. The thrombus originates in the neo-sinus, the regi...

Clinical valve thrombosis and subclinical leaflet thrombosis in transcatheter aortic heart valves: clinical manifestations, diagnosis, and treatment.

During the last decade, transcatheter aortic valve replacement (TAVR) has rapidly expanded as an alternative to surgical aortic valve replacement (SAVR) in patients with symptomatic severe aortic valve stenosis (AS) and increased surgical risk. In TAVR, a bioprosthetic valve is positioned within the stenotic native aortic valve. Although favorable short- and medium-term outcomes have been reported, thrombosis of the transcatheter heart valve (THV) has occurred, with two different entities being described: clinical valve thrombosis and subclinical leaflet thrombosis. In clinical valve thrombosis, an increase in transvalvular gradient appears as a result of obstructive thrombus formation, which eventually leads to symptoms of heart failure. Subclinical leaflet thrombosis is an incidental finding, characterized by a thin layer of thrombus covering the aortic site of the leaflet—called hypo-attenuating leaflet thickening (HALT)—as described on and defined by 4-dimensional computed tomography (4DCT) imaging. This phenomenon may affect motion of the leaflets and is then classified as hypo-attenuation affecting motion (HAM). Even in the case of HAM, the transvalvular pressure gradient remains within the normal range. Clinical valve thrombosis requires treatment, whereas the clinical impact and need for intervention in subclinical leaflet thrombosis is uncertain. Anticoagulant therapy protects against and resolves both clinical valve thrombosis and subclinical leaflet thrombosis, but studies exploring different antithrombotic strategies after TAVR are ongoing. This review summarizes currently available literature within the field of THV thrombosis and provides recommendations for a patient-tailored approach in TAVR patients, although guidelines are still lacking.

Complementary Role of the Computed Biomodelling through Finite Element Analysis and Computed Tomography for Diagnosis of Transcatheter Heart Valve Thrombosis.

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.

Subclinical leaflet thrombosis following transcatheter aortic valve replacement.

Since the inception of transcatheter aortic valve replacement (TAVR), there have been significant reductions in complications due to improvements of transcatheter heart valve (THV) designs and technologies. Given expanding TAVR applications, reducing complications further and better understanding THV durability has become a focus within the structural heart space. Recently, dedicated cardiac computed tomographic angiography (CTA) performed at 1 month post-TAVR has identified subclinical leaflet thrombosis (SLT), with rates as high as 40%. From the SLT imaging hallmarks of hypoattenuated leaflet thickening (HALT) to hypoattenuation affecting motion (HAM), a postulated timeline of THV thrombosis advancing to clinical symptoms can be recognized. This review article focuses on leaflet thrombosis particularly following TAVR explaining the spectrum of this disease process, its diagnosis, current treatment options, and future directions in the field.

Transcatheter Heart Valve Thrombosis: Incidence, Predictors, And Clinical Outcomes

Since its initial approval, the number of transcatheter aortic valve replacement procedures performed has increased exponentially with evolving indications that now include patients at intermediate risk for perioperative mortality following surgery. Multiple studies and reports have observed the phenomenon of leaflet dysfunction and thrombosis on follow-up imaging that may be associated with serious adverse outcomes. This review provides an insight into the incidence, predictors, management, and follow-up of transcatheter heartvalve thrombosis.

Echocardiographic features of post-transcatheter aortic valve implantation thrombosis and endocarditis.

Transcatheter heart valve thrombosis (THV-t) and endocarditis (THV-e) are relevant complications after transcatheter aortic valve implantation (TAVI). Transcatheter heart valve (THV) dysfunction definition is mostly based on Doppler (stenosis/regurgitation) without considering leaflets characteristics. To evaluate the additional diagnostic value of leaflets echocardiographic features over Doppler when prosthetic valve complication is suspected. Among 621 post-TAVI patients, 128 cases with probable valve complication were identified. THV-t was finally diagnosed in 13 patients (10%) and THV-e in 8 (6%), while the remaining 107 (84%) had no definitive diagnosis of thrombosis/endocarditis (THV-no). We analyzed at 2 time points (baseline and follow-up) both traditional Doppler parameters and leaflets morpho-functional features. Both Doppler and leaflets parameters showed high sensitivity (sensitivity 92%) and low specificity (ranging from specificity 32% to 74%) in detecting THV-t. Interestingly, the combination of mean aortic pressure gradient ≥20mmHg and leaflet thickening significantly improved the specificity of echocardiography for diagnosis of THV thrombosis (specificity 94%). On the other hand, echocardiographic diagnosis of THV endocarditis remained limited by very low sensitivity despite showing high specificity. The combination of Doppler and leaflets parameters can improve the echocardiographic diagnosis of THV thrombosis in post-TAVI patients with suspicious symptoms, via a significant increase in the overall test specificity. This would potentially allow more rational gatekeeping to more expensive/invasive diagnostic examinations (eg, CT scan) or therapeutic trials (eg, unnecessary anticoagulation).