- Email: [email protected]
Valve Thrombosis After Transcatheter Mitral Valve Replacement
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 68, NO. 16, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
Letters Patient #2 was a 34-year-old woman referred for
Valve Thrombosis After Transcatheter Mitral Valve Replacement
refractory heart failure secondary to a failing mitral annuloplasty. She expressed her desire for future pregnancy, and the heart team decided to perform TMVR using a 26-mm SAPIEN 3 THV. The final mean transmitral gradient was 2 mm Hg. Anticoagulant
Transcatheter mitral valve replacement (TMVR) is a
therapy with intravenous heparin was initiated
therapeutic option for patients with contraindication
immediately after the procedure, but the results
or high risk for surgical treatment and failed surgical
remained suboptimal during the first 24 h. On
bioprosthesis or annuloplasty, or even calcific mitral
day 2, TTE showed an increase in mean gradient to
valve disease (1,2). Concerns have been raised
12 mm Hg. The presence of thrombosis of 1 of the
regarding the risk of thrombosis of transcatheter
leaflets of the THV was confirmed with TEE and
heart valves (THVs) after transcatheter aortic valve
MDCT. After 3 weeks of aspirin and warfarin (inter-
replacement. Little is known about the risk of THV
national normalized ratio ¼ 3) therapy, the morpho-
thrombosis after TMVR.
logic features and motion of the leaflet were restored,
Seventy patients underwent TMVR through a
and the mean mitral gradient was 5 mm Hg.
transvenous transseptal approach using balloon-
Patient #3 was a 46-year-old man with a severe
expandable THVs (SAPIEN XT or SAPIEN 3, Edwards
chest deformation due to cyphoscoliosis and liver
Lifesciences, Irvine, California) at our institution.
cirrhosis. TMVR was performed for symptomatic se-
These patients received a combination of oral antico-
vere mitral stenosis and massive annular calcifica-
agulant agents and antiplatelet therapy for $3
tion. He received a 29-mm SAPIEN 3 THV. A second
months;
was
prosthesis was implanted to correct early backward
stopped in 27 patients (39%) in whom it was not indi-
displacement of the prosthesis and the presence of a
cated for another reason. Follow-up included trans-
moderate paravalvular leak. TTE before discharge
thoracic echocardiography (TTE), transesophageal
showed a mean transmitral gradient of 5 mm Hg and
echocardiography (TEE), and multidetector computed
a <2/4 paravalvular leak. The patient was discharged
tomography (MDCT) at 3 months, 1 year, and then
on day 7 with instructions to take anticoagulant
annually. The median follow-up duration was 14.5
agents. Four months later, he was asymptomatic,
months (range 7.4 to 22.8 months). THV thrombosis
and anticoagulant therapy had been discontinued.
was observed in 3 patients.
TEE images revealed mildly restrictive motion and
thereafter,
anticoagulant
therapy
Patient #1 was an 80-year-old woman with morbid
thickening of 1 leaflet and a mean transmitral
obesity and a failed mitral bioprosthesis with severe
gradient of 7 mm Hg. Long-term anticoagulant
regurgitation. A 26-mm SAPIEN XT THV was success-
therapy and aspirin were indicated. At 6-month
fully implanted. An echocardiogram confirmed the
follow-up,
absence of paravalvular leak and a mean transmitral
5 mm Hg, and the thrombosis had disappeared.
the
mean
transmitral
gradient
was
gradient of 4 mm Hg. The patient was discharged with
The incidence of THV thrombosis after TMVR
instructions to take aspirin and vitamin K antagonists,
remains largely unknown. Although it may occur
which were discontinued 3 months after the proced-
more frequently than after transcatheter aortic valve
ure. At 1-year follow-up, exertion dyspnea recurred.
replacement, only isolated cases have been reported
TTE showed an increase in the mean transmitral
up to now (3,4). Two of the 3 patients discussed here
gradient to 7 mm Hg. TEE and MDCT confirmed the
were asymptomatic at diagnosis, and therefore, this
presence of thrombosis and restricted motion of 2
complication may remain undiagnosed unless echo-
leaflets of the THV (Figures 1A and 1B). Lifelong anti-
cardiographic follow-up is systematically performed.
coagulant therapy combined with antiplatelet therapy
Moreover, only a mild increase of transmitral gradient
was indicated. One month later, echocardiography
was observed in 2 cases. Thus, thrombosis of a THV
showed a decrease in mean transmitral gradient to
may be overlooked if only TTE is performed. Sys-
5 mm Hg and resolution of the thrombosis.
tematic TEE may be necessary during follow-up of
JACC VOL. 68, NO. 16, 2016
Letters
OCTOBER 18, 2016:1814–20
F I G U R E 1 Multimodality Imaging of THV Thrombosis After TMVR
(A) A 3-dimensional transesophageal echocardiogram showing fusion and thickening of 2 leaflets of the SAPIEN XT (Edwards Lifesciences, Irvine, California) transcatheter heart valve (THV) implanted in Patient #1. (B) Double oblique multidetector computed tomography images showing the presence of thrombus in 2 of 3 leaflets of the transcatheter heart valve in the same patient. TMVR ¼ transcatheter mitral valve replacement.
these patients and is mandatory in patients with elevated transmitral gradients. Early or late subclinical THV thrombosis may occur frequently after TMVR, and long-term anticoagulant therapy may therefore be necessary in combi-
Please note: Dr. Himbert is a consultant and proctor for Edwards Lifesciences and Medtronic. Dr. Messika-Zeitoun is a proctor for Valtech; and has received research grants from Abbott and Edwards Lifesciences. Dr. Iung is a consultant for Boehringer Ingelheim; and has received speaker’s fees from Edwards Lifesciences. Dr. Vahanian has received speaker’s fees from Edwards Lifesciences, Abbott, and Valtech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
nation with antiplatelet therapy despite the increased bleeding risk. In all patients in this study, therapy with anticoagulant agents and aspirin rapidly restored valve function. Further studies are warranted. Giuliana Capretti, MD Marina Urena, MD, PhD *Dominique Himbert, MD Eric Brochet, MD Coppelia Goublaire, MD Constance Verdonk, MD Jose Luis Carrasco, MD Walid Ghodbane, MD David Messika-Zeitoun, MD, PhD Bernard Iung, MD, PhD Patrick Nataf, MD Alec Vahanian, MD *Department of Cardiology Bichat Claude Bernard Hospital Paris VII University 46 rue Henri Huchard
REFERENCES 1. Himbert D, Descoutures F, Brochet E, et al. Transvenous mitral valve replacement after failure of surgical ring annuloplasty. J Am Coll Cardiol 2012; 60:1205–6. 2. Himbert D, Bouleti C, Iung B, et al. Transcatheter valve replacement in patients with severe mitral valve disease and annular calcification. J Am Coll Cardiol 2014;64:2557–8. 3. Quick S, Speiser U, Strasser RH, Ibrahim K. First bioprosthesis thrombosis after transcatheter mitral valve-in-valve implantation: diagnosis and treatment. J Am Coll Cardiol 2014;63:e49. 4. Whisenant B, Jones K, Miller D, Horton S, Miner E. Thrombosis following mitral and tricuspid valve-in-valve replacement. J Thorac Cardiovasc Surg 2015;149:e26–9.
Ranolazine for Treatment of Angina or Dyspnea in Hypertrophic Cardiomyopathy Patients (RHYME)
75018 Paris France
Hypertrophic
E-mail: [email protected]
common inherited heart disease, is associated with
cardiomyopathy
(HCM),
the
most
http://dx.doi.org/10.1016/j.jacc.2016.07.757
ventricular arrhythmias and diastolic dysfunction
1815
VOL. 68, NO. 16, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
Letters Patient #2 was a 34-year-old woman referred for
Valve Thrombosis After Transcatheter Mitral Valve Replacement
refractory heart failure secondary to a failing mitral annuloplasty. She expressed her desire for future pregnancy, and the heart team decided to perform TMVR using a 26-mm SAPIEN 3 THV. The final mean transmitral gradient was 2 mm Hg. Anticoagulant
Transcatheter mitral valve replacement (TMVR) is a
therapy with intravenous heparin was initiated
therapeutic option for patients with contraindication
immediately after the procedure, but the results
or high risk for surgical treatment and failed surgical
remained suboptimal during the first 24 h. On
bioprosthesis or annuloplasty, or even calcific mitral
day 2, TTE showed an increase in mean gradient to
valve disease (1,2). Concerns have been raised
12 mm Hg. The presence of thrombosis of 1 of the
regarding the risk of thrombosis of transcatheter
leaflets of the THV was confirmed with TEE and
heart valves (THVs) after transcatheter aortic valve
MDCT. After 3 weeks of aspirin and warfarin (inter-
replacement. Little is known about the risk of THV
national normalized ratio ¼ 3) therapy, the morpho-
thrombosis after TMVR.
logic features and motion of the leaflet were restored,
Seventy patients underwent TMVR through a
and the mean mitral gradient was 5 mm Hg.
transvenous transseptal approach using balloon-
Patient #3 was a 46-year-old man with a severe
expandable THVs (SAPIEN XT or SAPIEN 3, Edwards
chest deformation due to cyphoscoliosis and liver
Lifesciences, Irvine, California) at our institution.
cirrhosis. TMVR was performed for symptomatic se-
These patients received a combination of oral antico-
vere mitral stenosis and massive annular calcifica-
agulant agents and antiplatelet therapy for $3
tion. He received a 29-mm SAPIEN 3 THV. A second
months;
was
prosthesis was implanted to correct early backward
stopped in 27 patients (39%) in whom it was not indi-
displacement of the prosthesis and the presence of a
cated for another reason. Follow-up included trans-
moderate paravalvular leak. TTE before discharge
thoracic echocardiography (TTE), transesophageal
showed a mean transmitral gradient of 5 mm Hg and
echocardiography (TEE), and multidetector computed
a <2/4 paravalvular leak. The patient was discharged
tomography (MDCT) at 3 months, 1 year, and then
on day 7 with instructions to take anticoagulant
annually. The median follow-up duration was 14.5
agents. Four months later, he was asymptomatic,
months (range 7.4 to 22.8 months). THV thrombosis
and anticoagulant therapy had been discontinued.
was observed in 3 patients.
TEE images revealed mildly restrictive motion and
thereafter,
anticoagulant
therapy
Patient #1 was an 80-year-old woman with morbid
thickening of 1 leaflet and a mean transmitral
obesity and a failed mitral bioprosthesis with severe
gradient of 7 mm Hg. Long-term anticoagulant
regurgitation. A 26-mm SAPIEN XT THV was success-
therapy and aspirin were indicated. At 6-month
fully implanted. An echocardiogram confirmed the
follow-up,
absence of paravalvular leak and a mean transmitral
5 mm Hg, and the thrombosis had disappeared.
the
mean
transmitral
gradient
was
gradient of 4 mm Hg. The patient was discharged with
The incidence of THV thrombosis after TMVR
instructions to take aspirin and vitamin K antagonists,
remains largely unknown. Although it may occur
which were discontinued 3 months after the proced-
more frequently than after transcatheter aortic valve
ure. At 1-year follow-up, exertion dyspnea recurred.
replacement, only isolated cases have been reported
TTE showed an increase in the mean transmitral
up to now (3,4). Two of the 3 patients discussed here
gradient to 7 mm Hg. TEE and MDCT confirmed the
were asymptomatic at diagnosis, and therefore, this
presence of thrombosis and restricted motion of 2
complication may remain undiagnosed unless echo-
leaflets of the THV (Figures 1A and 1B). Lifelong anti-
cardiographic follow-up is systematically performed.
coagulant therapy combined with antiplatelet therapy
Moreover, only a mild increase of transmitral gradient
was indicated. One month later, echocardiography
was observed in 2 cases. Thus, thrombosis of a THV
showed a decrease in mean transmitral gradient to
may be overlooked if only TTE is performed. Sys-
5 mm Hg and resolution of the thrombosis.
tematic TEE may be necessary during follow-up of
JACC VOL. 68, NO. 16, 2016
Letters
OCTOBER 18, 2016:1814–20
F I G U R E 1 Multimodality Imaging of THV Thrombosis After TMVR
(A) A 3-dimensional transesophageal echocardiogram showing fusion and thickening of 2 leaflets of the SAPIEN XT (Edwards Lifesciences, Irvine, California) transcatheter heart valve (THV) implanted in Patient #1. (B) Double oblique multidetector computed tomography images showing the presence of thrombus in 2 of 3 leaflets of the transcatheter heart valve in the same patient. TMVR ¼ transcatheter mitral valve replacement.
these patients and is mandatory in patients with elevated transmitral gradients. Early or late subclinical THV thrombosis may occur frequently after TMVR, and long-term anticoagulant therapy may therefore be necessary in combi-
Please note: Dr. Himbert is a consultant and proctor for Edwards Lifesciences and Medtronic. Dr. Messika-Zeitoun is a proctor for Valtech; and has received research grants from Abbott and Edwards Lifesciences. Dr. Iung is a consultant for Boehringer Ingelheim; and has received speaker’s fees from Edwards Lifesciences. Dr. Vahanian has received speaker’s fees from Edwards Lifesciences, Abbott, and Valtech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
nation with antiplatelet therapy despite the increased bleeding risk. In all patients in this study, therapy with anticoagulant agents and aspirin rapidly restored valve function. Further studies are warranted. Giuliana Capretti, MD Marina Urena, MD, PhD *Dominique Himbert, MD Eric Brochet, MD Coppelia Goublaire, MD Constance Verdonk, MD Jose Luis Carrasco, MD Walid Ghodbane, MD David Messika-Zeitoun, MD, PhD Bernard Iung, MD, PhD Patrick Nataf, MD Alec Vahanian, MD *Department of Cardiology Bichat Claude Bernard Hospital Paris VII University 46 rue Henri Huchard
REFERENCES 1. Himbert D, Descoutures F, Brochet E, et al. Transvenous mitral valve replacement after failure of surgical ring annuloplasty. J Am Coll Cardiol 2012; 60:1205–6. 2. Himbert D, Bouleti C, Iung B, et al. Transcatheter valve replacement in patients with severe mitral valve disease and annular calcification. J Am Coll Cardiol 2014;64:2557–8. 3. Quick S, Speiser U, Strasser RH, Ibrahim K. First bioprosthesis thrombosis after transcatheter mitral valve-in-valve implantation: diagnosis and treatment. J Am Coll Cardiol 2014;63:e49. 4. Whisenant B, Jones K, Miller D, Horton S, Miner E. Thrombosis following mitral and tricuspid valve-in-valve replacement. J Thorac Cardiovasc Surg 2015;149:e26–9.
Ranolazine for Treatment of Angina or Dyspnea in Hypertrophic Cardiomyopathy Patients (RHYME)
75018 Paris France
Hypertrophic
E-mail: [email protected]
common inherited heart disease, is associated with
cardiomyopathy
(HCM),
the
most
http://dx.doi.org/10.1016/j.jacc.2016.07.757
ventricular arrhythmias and diastolic dysfunction
1815