Leaflet Immobility and Thrombosis in Transcatheter Aortic Valve Replacement

Arnold C. T. Ng; David R. Holmes; Michael J. Mack; Victoria Delgado; Raj Makkar; Philipp Blanke; Jonathon A. Leipsic; Martin B. Leon; Jeroen J. Bax


Eur Heart J. 2020;41(33):3184-3197. 

In This Article

Bioprosthetic Valve Dysfunction

With the exponential growth of TAVR worldwide, valve durability is now a central consideration as the procedure moves towards becoming the dominant treatment strategy for aortic stenosis irrespective of surgical risk scores. To date, there have been several attempts to define structural valve deterioration (SVD) primarily based on the echocardiographic quantification of valvular stenosis or paravalvular regurgitation.[4–6] However, they are severely limited by highly variable echocardiographic criteria and do not provide insights into the pathophysiology of SVD. To facilitate and direct future research, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) has proposed standardized definitions for valve dysfunction in conjunction with the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS).[4] In their consensus statement, the task force proposed that bioprosthetic valve dysfunction may be categorized into SVD, non-SVD, thrombosis or endocarditis (Figure 1). Importantly, SVD was defined as irreversible valve dysfunction, whereas thrombosis and endocarditis are potential reversible causes of valve dysfunction and should be categorized separately. However, valve leaflet thrombosis can result in permanent dysfunction leading to bioprosthetic valve failure. Finally, bioprosthetic valve failure (a clinical correlate) was defined as valve dysfunction detected on autopsy likely causing death, valve reintervention (i.e. valve-in-valve, paravalvular leak closure or SAVR), or severe haemodynamic SVD. Over the last few years, it has been recognized that THV thrombosis is often under-diagnosed and may be a potential cause of valvular dysfunction.

Figure 1.

Causes of bioprosthetic valve dysfunction. Reproduced with permission.4