1. Kyle D Buchanan, MD MedStar Washington Hospital Center
Bioprosthetic Leaflet Thrombosis of Valve-in-Valve Self-Expanding Transcatheter Device
Kyle D Buchanan, MD
MedStar Washington Hospital Center

2. Kyle D Buchanan, MD
I have no relevant financial relationships

3. Learning objectives
Management of subacute paravalvular bioprosthetic aortic regurgitation.
Imaging techniques for the diagnosis of bioprosthetic leaflet thrombosis.
Treatment and outcomes of bioprosthetic leaflet thrombosis.

4. Clinical Presentation
87 year-old female with severe aortic stenosis and symptoms of NYHA Class III dyspnea.
Successful implantation of 29 mm Evolut R CoreValve via the transfemoral approach.
TAVR procedure complicated by development of heart block requiring permanent pacemaker placement.
Discharge echocardiogram demonstrated mild to moderate transvalvular aortic regurgitation.

5. Clinical Presentation
Readmitted with recurrent NYHA Class III heart failure symptoms one month following TAVR.
Echocardiogram demonstrated moderate posterior paravalvular regurgitation.

6. Clinical Presentation
Readmitted with recurrent NYHA Class III heart failure symptoms one month following TAVR.
Echocardiogram demonstrated moderate posterior paravalvular regurgitation.

7. Clinical Presentation
Successful abolition of aortic regurgitation with placement of second 29 mm Evolut R CoreValve.

8. Clinical Presentation
6-month follow-up clinic visit.
Functionally limited by lumbar compression fractures but ambulates with walker.
Denies significant dyspnea, chest pain, dizziness, syncope, PND, orthopnea, and lower extremity swelling.
Maintains regular follow-up with general Cardiologist.
Compliant with Apixaban treatment for atrial fibrillation

9. Clinical Presentation
6-month follow-up echo demonstrated normal functioning bioprosthetic valve with no regurgitation.

10. Imaging studies
“Right” and “left” cusp leaflet thickening. Normal non-coronary cusp.
“LCC”
“RCC”
“RCC”
“NCC”

11. Imaging studies
“RCC”
“NCC”
“LCC”

12. Imaging studies

13. Imaging studies

14. Follow-Up
Apixaban discontinued, transitioned to Warfarin therapy (goal INR 2-3).
Repeat CT scan to be completed following 3 months of Warfarin treatment.
Repeat imaging will be available for presentation in February at CRT 2017.

15. Take Home Messages
Subclinical leaflet thrombosis may occur during Factor Xa inhibitor therapy.
Valve-in-valve prosthesis hemodynamics may portend higher risk of leaflet thrombosis.
TTE is not sufficient to diagnose subclinical leaflet thrombosis, CT or TEE is required.
Treatment with Warfarin, results are pending.