ESC Focus on Interventions & PC - 15

ESC Congress 2017

In Review

Interventions &
Peripheral Circulation
angiographic guidance without TOE [Attizzani GE et al.
Am J Cardiol. 2015] there is no immediate detection
of complications without echo [Kronzon I et al. JACC
Cardiovasc Imaging. 2015].
Joseph F. Maalouf MD, Mayo Clinic, Rochester,
Minnesota, USA, shared his checklist of the items to
examine before performing a TAVI/TAVR.
Confirming a tri-leaflet atrioventricular morphology
and aortic valve annular sizing are at the top of his list.
Determining the aortic valve annular dimensions with
echocardiography is critical for heart valve placement.
CT is the method of choice for measuring aortic valve
annular diameter, annular area and perimeter for most
patients. Valve undersizing can lead to paravalvular
regurgitation and valve embolisation; while oversizing
can cause under expansion of the transcatheter valve,
annular rupture, conduction disturbances, and reduced
valve durability. An optimal approach to ensure a good
seal and minimal paravalvular leaking and stable seating of the valve is controlled oversizing [Hahn RT et al.
JACC Cardiovasc Imaging. 2015].
Next on the checklist is comprehensive evaluation of
the entire aortic valve complex landing zone, including the
sinus of Valsalva height and diameter; height of the coronary ostia and in particular the left main coronary ostium
above the annulus; and the sinotubular junction diameter.
Third on the checklist is assessing the extent/asymmetry
of the annular/root and outflow tract calcification. Fourth,
check for the presence/degree of aortic, mitral, and tricuspid regurgitation, and left/right ventricular function,
then for sigmoid septum/basal septal hypertrophy/left
ventricular outflow tract obstruction and exclude intracardiac mass/thrombus and pericardial effusion. Finally
check access issues such as transapical access and thoracic aorta atheroma.
Samir Kapadia, MD, Cleveland Clinic, Cleveland, Ohio,
USA discussed strategies for anticoagulation post-TAVI/
TAVR to prevent thrombosis while considering bleeding
risk (Table 1).

Post TAVI/TAVR pharmacologic considerations
include whether to use single or dual antiplatelet therapy, warfarin or one of the new oral anticoagulants
(NOAC), or a combination of antiplatelet and anticoagulation therapy. Given the potential for thrombosis
and/or bleeding with anticoagulation, important considerations should include patient characteristics, TAVR
device type, the profile of the various pharmacologic
agents, and duration of therapy.
Among 890 patients in the RESOLVE and SAVORY
Registries subclinical leaflet thrombosis was identified
by CT scan in 12% (106/890) of patients with bioprosthetic aortic valves, more commonly in transcatheter 13% (101/752) than in surgical valves 4% (5/138)
[Chakravarty T et al. Lancet. 2017]. A greater proportion
of patients with subclinical leaflet thrombosis had aortic
valve gradients > 20 mm Hg and increases in aortic valve
gradients > 10 mm Hg than did those with normal leaflet motion (Figure 2). Risk factors for gradient increases
include high BMI, valve ≤ 23 mm, valve in valve, and no
anticoagulation treatment at discharge [Del Trigo M et
al. J Am Coll Cardiol. 2016].

Table 1. Strategies for Anticoagulation Post-TAVI/TAVR

The risk of leaflet thickening is associated with
regional transcatheter heart valve (THV) stent frame
under expansion [Fuchs A et a. Eurointervention. 2017].
Post-dilatation of self-expanding THV, as well as a supraannular valve position seem to reduce the occurrence
of this phenomenon. Overexpansion by > 10% of the
SAPIEN 3 valve was associated with more thrombus. With
the CoreValve Evolut R, the thrombus volume increased
linearly with implant depth. A supra-annular neo-sinus
may reduce thrombosis risk due to reduced flow stasis
[Midha RA et al. Circulation. 2017]. Anticoagulation with
NOACs or warfarin, but not antiplatelet therapy, reduces
leaflet motion and resolves thrombosis, but large randomised studies proving this prospectively are still missing.
Patients on anticoagulants have a 5% higher risk of
major bleeding and late bleeding is associated with a

Thrombosis

Bleeding
Patient Factors

*
*
*
*

Low cardiac output
Atrial fibrillation
Small sinuses
Bulky calcifications

Device Characteristics
*
*
*
*

Annular or supra-annular
Commissural height
"Stent cover"
Radial strength

Procedural Factors
* Depth of Implantation
* Symmetric expansion
* Appropriate sizing

* Age
* Gender
* Renal dysfunction
Pharmacologic Options
*
*
*
*

ASA
Clopidogrel
Warfarin
NOAC

Other Options
* LAA occlusion

ASA, aspirin; LAA, left atrial appendage occlusion; NOAC, non-vitamin K oral
anticoagulant.

Figure 2. Reduced Leaflet Motion and Increased Gradients
Normal Leaflet Motion
Reduced Leaflet Motion
10.0

P = .0002

16.0

15/96
(16%)

P < .0001

13/88
(15%)

P < .0001
12/88
(14%)

Prevalence

14.0
12.0
10.0
8.0
6.0

40/714
(6%)

4.0
9/632
(1%)

2.0
0.0

Mean aortic gradient
> 20 mm Hg

Increase in gradient
> 10 mm Hg

7/632
(1%)
Mean aortic gradient > 20 mm Hg
and
Increase in gradient > 10 mm Hg

Source: Chakravarty T et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet. 2017;389:2383-2392.

Official Peer-Reviewed Highlights From ESC Congress 2017

Table of Contents for the Digital Edition of ESC Focus on Interventions & PC