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Subclinical Leaflet Thrombosis and Anticoagulation After Transcatheter Aortic Valve ReplacementA Review

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JAMA Cardiology

Published Online: June 22, 2022

Review

Article Information and Disclosures

Thomas J. Cahill, MB, BS, DPhil¹;

Ajay J. Kirtane, MD, SM¹;

Martin Leon, MD¹;

Susheel K. Kodali, MD¹

Author Affiliations

¹Structural Heart & Valve Center, New York–Presbyterian Hospital/Columbia University Irving Medical Center, New York

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Abstract

Importance Subclinical leaflet thrombosis affects approximately 15% of patients after transcatheter aortic valve replacement (TAVR). The pathophysiology and clinical significance of leaflet thrombosis remain incompletely understood. Defining the optimal management strategy in patients who are asymptomatic, including the role for oral anticoagulation (OAC), is a key challenge for the field.

Observations Three recent randomized trials have evaluated the role of OAC in patients after TAVR. These studies have confirmed prior observational data suggesting that OAC is effective at prevention of subclinical leaflet thrombosis. Overall, however, OAC does not lead to a clinical benefit over the period studied, and in some patients may be harmful owing to bleeding risk.

Conclusions and Relevance Strategies for identification of patients in whom the benefit of OAC outweighs the risks are required for optimization of long-term outcome after TAVR. This requires clearer insights into the mechanisms of asymptomatic leaflet thrombosis, its clinical significance, and patient-specific risks of bleeding and structural valve degeneration.

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Article Information

Accepted for Publication: April 20, 2022.

Published Online: June 22, 2022. doi:10.1001/jamacardio.2022.1591

Corresponding Author: Susheel Kodali, MD, Structural Heart & Valve Center, New York–Presbyterian Hospital/Columbia University Irving Medical Center, 177 Fort Washington Ave, 5th Floor, Room 5C-501, New York, NY 10032 (sk2427@columbia.edu).

Author Contributions: Dr Kodali had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cahill, Kirtane, Kodali.

Acquisition, analysis, or interpretation of data: Cahill, Leon.

Drafting of the manuscript: Cahill.

Critical revision of the manuscript for important intellectual content: All authors.

Supervision: Kirtane, Leon, Kodali.

Conflict of Interest Disclosures: Dr Kirtane reported receiving institutional funding from Medtronic, Boston Scientific, Abbott Vascular, Amgen, CSI, CathWorks, Siemens, Philips, Neurotronic, Biotronik, Chiesi, Bolt Medical, and ReCor Medical; fees paid to Columbia University and/or Cardiovascular Research Foundation for speaking engagements and/or consulting in which he controlled the content; being a consultant for Neurotronic; receiving travel expenses/meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron; and working as Associate Editor for JAMA Cardiology. Dr Leon reported being an early physician founder of and having an equity relationship with (<1% of the company) Mitralign. Dr Kodali reported receiving consultant honoraria from Admedus, Dura Biotech, TriCares, Philips, and TriFlo; having equity in Dura Biotech, MicroInterventional Devices, Thubrikar Aortic Valve Inc, Supira, Admedus, TriFlo, Tioga, X-Dot, and Adona; and receiving institutional research grants from Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific, and JenaValve. No other disclosures were reported.

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