1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; 2Universitätsmedizin Mainz Klinik für Poliklinik für Diagnostische und Interventionelle Radiologie Mainz, Deutschland; 3Universitätsmedizin Mainz Klinik und Poliklinik für Herz- und Gefäßchirurgie Mainz, Deutschland
Introduction:
While thrombosis is a potential problem with impact on prosthesis durability, data on incidence and predictors is still limited.
Methods and results:
We searched our center’s database for all clinical apparent TAVR-thromboses (apparent by clinical hint and/or elevated gradients in follow-ups and proved by typical morphology of thrombosis in CT-scan) between 1/2018-7/23. 73 Patients (3.0% of the total cohort) were identified with apparent TAVR-thrombosis (43.8% females, mean age 80.2 +/- 6.8 years, mean EuroSCORE II 4.9 +/- 4.3, 4.1% Valve-in-Valve procedure). Of those, 67 (91.2%) were treated with a BE-Prosthesis and entered our analysis. These were compared to a matched control group (n=110, all consecutive patients consecutively treated by TAVR in our site between 1/23 and 6/23 matched for BE-Prosthesis without hint for apparent thrombosis in follow-up).
While no difference in age (p=0.318), female sex (43.3 vs. 37.3%, p=0.434), baseline LVEF (55 (55/59) vs. 55% (46/60), p=0.162) or underlying valve morphology (functional or congenital bicuspidy 29.7 vs. 26.9%, p=0.727) could be detected, patients with later valve thrombosis had a lower risk profile (Euroscore II 3.2 (1.9/5.6) vs. 5.3 (2.6/10.0), p=0.001), were less likely treated with lipid-lowering therapy (59.7 vs. 83.3%, p<0.001) and had smaller anatomies (annular minimal diameter 21.1 (20.1/23.4) vs. 22.3 (20.8/24.1), p=0.021; LVOT area 437 (381/494) vs. 485mm (408/560), p=0.009, area of SOV 810 (688/910) vs 889mm2 (769/1019), p=0.010) including short intraventricular septum (<2 mm, 38.5 vs. 12.5%, p=0.007). No relevant differences in prosthesis-size (p=0.771), administration of Protamine post intervention (40.9 vs. 40.2%, p>0.99) and postprocedural complications (e.g., groin complications 3.0 vs 5.5%, p=0.712) as well as bleedings requiring transfusion within 7 days (6.0 vs. 11.0%, p=0.295) were detected. Nevertheless, there was a trend towards a higher rate of pre-BAV (28.4 vs. 15.5%, p=0.053) and a higher rate of infections during index visit (20.9 vs. 11.9%, p=0.133) in patients with later thrombosis. Of all initial anticoagulant regimen post implantation, patients with thrombosis were mostly not treated with OAC (23.9 vs. 55.5%, p<0.001), whereas no differences regarding treatment with SAPT vs. DAPT (p=0.639) were observed. Medication with OAC post TAVI was strongly associated with lower likelihood for later TAVR-Thrombosis (OR 0.25 (0.13/0.50), p<0.001).
Discussion and Conclusion:
We documented a rather low rate of apparent thrombosis after TAVR-implantation in analogy to previously reported data of other registries. Patients with smaller anatomies, short intraventricular septum length and those without lipid-lowering therapy were more likely to develop TAVR-thrombosis. Postinterventional oral anticoagulation is strongly protective against later prosthesis thrombosis.