Response to anticoagulant treatment in clinical apparent thrombosis of transcatheter aortic valve replacement in a monocentric retrospective cohort

Martin Geyer (Mainz)1, S. Bredeek (Mainz)1, Y. Yang (Mainz)2, M. Ahoopai (Mainz)1, T. Ruf (Mainz)1, A. R. Tamm (Mainz)1, T. Gößler (Mainz)1, M. A. Rogmann (Mainz)1, M. Oberhoffer (Mainz)3, F. Masseli (Mainz)3, P. Lurz (Mainz)1, R. S. von Bardeleben (Mainz)1

1Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; 2Universitätsmedizin Mainz Klinik für Diagnostische und Interventionelle Radiologie Mainz, Deutschland; 3Universitätsmedizin Mainz Klinik und Poliklinik für Herz- und Gefäßchirurgie Mainz, Deutschland



Leaflet thrombosis of the transcatheter aortic valve prosthesis can be observed in a small percentage of patients but represent a clinically relevant diagnosis. We here analysis the potential of anticoagulant therapy to reverse leaflet thrombosis.


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 and 7/23. Overall, 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, 47 had echocardiographic follow-up (in mean 100 +/- 85 days to follow-up) and entered the analysis. 27 (57%) were treated by NOAC, 17 (36%) by VKA, of those 20 (42%) combined to ASS or a P2Y12 inhibitor. We defined a group of echocardiographic “responders” in patients with a reduction in mean gradient over the TAVR-prosthesis of at least 20% at follow-ups compared to the echo at diagnosis of thrombosis.

60% of the patients (n=27) had a reduction of gradients by at least 20% at follow-up. While there were no significant differences in most baseline- and periprocedural parameters (e.g., female sex 37.0 vs. 38.9%, p>0.99, Euroscore II (2.8 (2.1/4.1) vs. 3.3 (1.5/7.7), p=0.660, renal impairment 92.6 vs. 77.8%, p=0.199, atrial fibrillation 3.7 vs. 22.2, p=0.141, tumor 14.8 vs. 27.8%, p=0.449, congenital/functional bicuspidy 34.6 vs. 18.8%, p=0.316, BE-Prosthesis 96.3 vs. 83.3%, p=0.286, Valve-in-Valve TAVR in 3.7 vs. 11.1%, p=0.555), patients with gradient-reduction were more likely to have lower intial levels of sPAP (32 (29/41) vs. 35mmHg (31/48), p=0.022) and bigger anatomies (minimal annulus diameter 21.3 (20.5/23.5) vs. 20.8mm (19.8/21.7), p=0.073, mean RC-height 19 (17/20) vs. 16mm (14/20), p=0.047).


Novel intake of OAC after diagnosis of TAVR-thrombosis was strongly associated with gradient-reduction (92.3 vs. 66.7%, p=0.048; OR=6.0 (1.1/34.3), p=0.044), while patients developing thrombosis despite pre-medication on OAC were overrepresented in the group of those without relevant gradient-reduction (96.3 vs. 72.2%, p=0.031). No statistically significant effect of an additional therapy with P2Y12-inhibitors (OR 1.16 (0.31/4.35), p=0.831) could be proven. Early diagnosis of thrombosis < 90 days post TAVR was strongly associated with gradient-reduction (OR 10 (1.9/52.3), p=0.006). No difference could be found when comparing VKA vs. DOAC as anticoagulant after diagnosis of TAVR-thrombosis (OR 1.1 (0.3/3.7), p=0.939).


Discussion and conclusion:

TAVR-thrombosis has a relevant rate patients not responding to anticoagulant therapy by relevant gradient-reduction, especially those developing thrombosis despite pre-medication of OAC. Early diagnosis of thrombosis and novel medication of OAC are strongly predictive for successful treatment, while no differences comparing VKA vs. DOAC and/or additional therapy with a P2Y12-inhibitor could be proven in this retrospective database.

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