Author + information
- Received April 7, 2015
- Accepted April 25, 2015
- Published online August 17, 2015.
- David Martí, MD, PhD∗∗ (, )
- Miguel Rubio, MD†,
- Natalia Escribano, MD‡,
- Ramón de Miguel, MD†,
- Ignacio Rada, MD, PhD∗ and
- César Morís, MD, PhD§
- ∗Interventional Cardiology Unit, Department of Cardiology, Central Defense Hospital, University of Alcalá, Madrid, Spain
- †Department of Cardiac Surgery, Central Defense Hospital, University of Alcalá, Madrid, Spain
- ‡Department of Pathology, Central Defense Hospital, University of Alcalá, Madrid, Spain
- §Department of Cardiology, Central University Hospital of Asturias, Oviedo, Spain
- ↵∗Reprint requests and correspondence:
Dr. David Martí Sánchez, Unidad de Cardiología Intervencionista, Hospital Central de la Defensa, Glorieta del Ejercito S/N, 28047 Madrid, Spain.
An 85-year-old man presented with dyspnea New York Heart Association functional class IV 4 years after implantation of a 26-mm CoreValve transcatheter aortic valve (TAV) (Medtronic, Minneapolis, Minnesota). Angiography revealed severe aortic regurgitation due to the deep position of the prosthesis (Online Video 1), and a 23-mm SAPIEN XT (Edwards Lifesciences, Irvine, California) valve-in-valve implantation was performed. Mid-term follow-up was favorable; clopidogrel was discontinued 15 months after the SAPIEN XT valve implantation, and aspirin monotherapy continued thereafter.
Two months after clopidogrel discontinuation, the patient required 3 visits to the emergency department with overt heart failure. Echocardiography showed high transvalvular gradients (peak, 55 mm Hg; mean, 31 mm Hg; dimensionless valve index, 0.25), thickened leaflets, and mild to moderate central aortic regurgitation (Figure 1, Online Videos 2 and 3). The heart team decided to perform a surgical aortic valve replacement. Operative and pathology findings revealed a diffuse fibrin-platelet thrombus adhered to the aortic surface on the 3 SAPIEN XT valve cusps (Figures 2 and 3). This valve was partially denuded and easily extracted from within the CoreValve prosthesis. Both TAVs were explanted via a longitudinal aortotomy, and a 21-mm bioprosthesis was sutured to the well-preserved aortic annulus. Unfortunately, the patient died of cardiac arrest in the postoperative period.
Valve thrombosis is a rare but increasingly recognized complication of transcatheter heart valves. Indeed, a systematic review has shown that thrombosis is the major cause of valve stenosis in the early years after implantation (1). As in this case, TAV thrombosis is usually not associated with typical thrombus images on transesophageal echocardiography, and operators must be cautious when handling catheters in the vicinity of a stenotic TAV (1,2).
Balloon-expandable prostheses are sometimes used to reduce aortic regurgitation after CoreValve implantation (3). Our findings suggest that in this setting, internal prosthesis endothelialization may be delayed or incomplete, representing an additional risk factor for late thrombosis. Therefore, TAV-in-TAV therapies with balloon-expandable valves might require longer duration of dual-antiplatelet therapy.
For supplemental videos, please see the online version of this paper.
Dr. Morís is a proctor and consultant for and a member of the Scientific Advisory Board of Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 7, 2015.
- Accepted April 25, 2015.
- 2015 American College of Cardiology Foundation