Subclinical valve thrombosis in transcatheter aortic valve implantation: A systematic review and meta-analysis

Kei Woldendorp; Mathew P Doyle; Deborah Black; Martin Ng; Anthony Keech; Stuart M Grieve; Paul G Bannon

doi:10.1016/j.jtcvs.2020.01.084

Subclinical valve thrombosis in transcatheter aortic valve implantation: A systematic review and meta-analysis

J Thorac Cardiovasc Surg. 2021 Nov;162(5):1491-1499.e2. doi: 10.1016/j.jtcvs.2020.01.084. Epub 2020 Feb 19.

Authors

Kei Woldendorp¹, Mathew P Doyle², Deborah Black³, Martin Ng⁴, Anthony Keech⁴, Stuart M Grieve⁵, Paul G Bannon⁶

Affiliations

¹ Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.
² The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.
³ Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.
⁴ Sydney Medical School, The University of Sydney, Sydney, Australia; Cardiology Department, Royal Prince Alfred Hospital, Sydney, Australia.
⁵ Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia; Sydney Translational Imaging Laboratory, Heart Research Institute & Charles Perkins Centre, Sydney Medical School, University of Sydney, Sydney, Australia.
⁶ Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia. Electronic address: pgbannon@gmail.com.

PMID: 32217021
DOI: 10.1016/j.jtcvs.2020.01.084

Abstract

Background: Recent high-resolution computed tomography studies after transcatheter aortic valve insertion (TAVI) have reported a high prevalence of subclinical valve thrombosis (SCVT), potentially contributing to increased risk of late stroke. We aimed to investigate SCVT in patients after TAVI, with a focus on prevalence, predisposing factors, management, and potential sequelae.

Methods: A comprehensive literature review of patients with SCVT after TAVI was carried out on all published studies in 3 major electronic databases from their inception until October 2019. Studies with sufficient data were included in a meta-analysis comparing the risk of stroke between patients with SCVT and those with normal valve function, as well as the protective effects of antiplatelet and anticoagulation on preventing SCVT.

Results: From 3456 patients examined in a comprehensive review, 398 patients (11.5%) demonstrated evidence of SCVT during follow-up. Dual antiplatelet therapy was given in 45.5% of cases, single antiplatelet therapy in 19.8%, and oral anticoagulation in 28.5%. A meta-analysis demonstrated that rates of stroke were more than 3 times greater in patients with SCVT compared with those without (logistic odds, 1.10; 95% confidence interval, 0.63-1.57, P < .0001). Oral anticoagulation was superior to dual antiplatelet therapy or single antiplatelet therapy, preventing the formation of SCVT (logistic odds, -1.05, 95% confidence interval, -1.71 to -0.39, P < .0001).

Conclusions: Subclinical valve thrombosis is seen in 11.5% of patients after TAVI and is associated with increased risk of stroke. When oral anticoagulation is used postprocedurally, it is more effective than either dual or single-antiplatelet therapy in preventing subclinical valve thrombosis. These findings suggest that further studies are needed to define the optimal antithrombotic regimen to mitigate thrombotic and embolic sequelae after TAVI.

Keywords: TAVI; stroke; subclinical valve thrombosis; transcatheter aortic valve; valve dysfunction.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Aged
Aged, 80 and over
Anticoagulants / therapeutic use
Aortic Valve / diagnostic imaging
Aortic Valve / physiopathology
Aortic Valve / surgery*
Asymptomatic Diseases
Female
Fibrinolytic Agents / therapeutic use
Heart Valve Prosthesis*
Humans
Male
Middle Aged
Platelet Aggregation Inhibitors / therapeutic use
Risk Assessment
Risk Factors
Stroke / etiology
Stroke / prevention & control
Thrombosis / diagnostic imaging
Thrombosis / etiology*
Thrombosis / physiopathology
Thrombosis / prevention & control
Transcatheter Aortic Valve Replacement / adverse effects*
Transcatheter Aortic Valve Replacement / instrumentation*
Treatment Outcome

Substances

Anticoagulants
Fibrinolytic Agents
Platelet Aggregation Inhibitors