Systematic CT Methodology for the Evaluation of Subclinical Leaflet Thrombosis

• Published in: JACC. Cardiovascular imaging Vol. 10; no. 4; pp. 461 - 470
• Main Authors: Jilaihawi, Hasan, Asch, Federico M., Manasse, Eric, Ruiz, Carlos E., Jelnin, Vladimir, Kashif, Mohammad, Kawamori, Hiroyuki, Maeno, Yoshio, Kazuno, Yoshio, Takahashi, Nobuyuki, Olson, Richard, Alkhatib, Joe, Berman, Daniel, Friedman, John, Gellada, Norman, Chakravarty, Tarun, Makkar, Raj R.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2017
• Subjects: aortic stenosis; Aortic Valve - diagnostic imaging; Aortic Valve - physiopathology; Aortic Valve - surgery; aortic valve replacement; Asymptomatic Diseases; Bioprosthesis; Cardiovascular; Echocardiography, Transesophageal; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - instrumentation; Humans; leaflet thrombosis; Predictive Value of Tests; Risk Factors; Severity of Illness Index; TAVI; TAVR; Thrombosis - diagnostic imaging; Thrombosis - etiology; Thrombosis - therapy; Tomography, X-Ray Computed; transcatheter aortic valve implantation; transcatheter aortic valve replacement; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - instrumentation; Treatment Outcome; transcatheter aortic valve implantation; HALT; aortic valve replacement; TAVI; HU; TAVR; MPR; CT; AS; RELM; aortic stenosis; HAM; TEE; leaflet thrombosis; transcatheter aortic valve replacement; SOV; VR; hypoattenuated leaflet thickening; volume rendered; hypoattenuation affecting motion; computed tomography; Hounsfield unit; sinus of Valsalva; multiplanar reconstruction; reduced leaflet motion; transesophageal echocardiography
• ISSN: 1936-878X; 1876-7591; 1876-7591
• DOI: 10.1016/j.jcmg.2017.02.005

Subclinical leaflet thrombosis was recently described in a randomized trial of transcatheter aortic valve replacement. It was subsequently demonstrated in a series of registries that this was a commonly observed imaging finding seen in all transcatheter and surgical bioprostheses. The phenomenon has aroused considerable interest due to the as-yet-undefined risk for later clinical events and the possibility of pharmacological intervention with anticoagulation. Subclinical leaflet thrombosis is easily detected noninvasively by technically suitable computed tomography (CT) with a high degree of concordance to transesophageal echocardiography findings. The CT hallmarks were noted to be hypoattenuated leaflet thickening (HALT) associated with reduced leaflet motion (RELM). The combination of HALT and RELM signified hypoattenuation affecting motion, the standardized imaging endpoint used. This paper describes the systematic CT evaluation methodology that was devised during the Portico trial investigation and U.S. Food and Drug Administration submission; it also highlights the need for an ongoing discussion among experts to enable, with the help of the Valve Academic Research Consortium, standardization of reporting of this imaging finding to cater to the present and future needs of clinical trials. [Display omitted]