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      Impact of Antithrombotic Regimen and Platelet Inhibition Extent on Leaflet Thrombosis Detected by Cardiac MDCT after Transcatheter Aortic Valve Replacement

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          Abstract

          The impact of antithrombotic regimen and platelet inhibition extent on subclinical leaflet thrombosis (SLT) detected by cardiac multidetector computed tomography (MDCT) after transcatheter aortic valve replacement (TAVR) is not well established. Hypoattenuation affecting motion (HAM) has been proposed as a surrogate marker of SLT, and is characterized by hypoattenuated leaflet thickening (HALT) and concomitant reduction in leaflet motion (RELM). We sought to investigate (i) the prevalence of HAM and HALT after TAVR detected by MDCT, (ii) the predictors of SLT, (iii) the impact of oral anticoagulant (OAC) and platelet inhibition extent assessed by platelet reactivity index vasodilator stimulated phosphoprotein (PRI-VASP) and closure time adenosine diphosphate (CT-ADP) on SLT. Of 187 consecutive patients who underwent TAVR from 1 August 2017 to 31 March 2018, 90 of them had cardiac CT at relevant follow-up. Clinical, biological, echocardiographic, procedural characteristics and treatments were collected before, at discharge, and 1 year after TAVR. P2Y 12 platelet inhibition extent and primary haemostasis disorders were investigated using platelet PRI-VASP and CT-ADP point-of-care assays. Eighty-five post-TAVR CTs out of 90 were ranked for clarity and assessed with sufficient diagnostic quality. HAM was evidenced in 13 patients (15.3%) and HALT in 30 patients (35%). Procedural characteristics, including aortic valve calcium score, annulus size, or procedural heparin regimens, were equivalent between groups. Likewise, no impact of P2Y 12 inhibition (PRI-VASP) nor primary haemostasis disorders (CT-ADP) on SLT could be evidenced. No impact of SLT on valve deterioration evaluated by transthoracic echocardiography (TTE) and clinical events could be established at 12 months follow-up. By multivariate analysis, lack of oral anticoagulant therapy at discharge (HR 12.130 CI 95% (1.394–150.582); p = 0.028) and higher haemoglobin levels were evidenced as the sole independent predictors of SLT. In four patients with HAM, MDCT follow-up was obtained after initiation of OAC therapy and showed a complete regression of HAM. SLT was evidenced in a sizeable proportion of patients treated by TAVR and was mainly determined by the lack of oral anticoagulant therapy. Conversely, no impact of platelet inhibition extent on SLT could be evidenced.

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          Most cited references 25

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          Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study.

          Subclinical leaflet thrombosis of bioprosthetic aortic valves after transcatheter valve replacement (TAVR) and surgical aortic valve replacement (SAVR) has been found with CT imaging. The objective of this study was to report the prevalence of subclinical leaflet thrombosis in surgical and transcatheter aortic valves and the effect of novel oral anticoagulants (NOACs) on the subclinical leaflet thrombosis and subsequent valve haemodynamics and clinical outcomes on the basis of two registries of patients who had CT imaging done after TAVR or SAVR.
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            Bleeding and stent thrombosis on P2Y12-inhibitors: collaborative analysis on the role of platelet reactivity for risk stratification after percutaneous coronary intervention.

            Although platelet reactivity during P2Y12-inhibitors is associated with stent thrombosis (ST) and bleeding, standardized and clinically validated thresholds for accurate risk stratification after percutaneous coronary intervention (PCI) are lacking. We sought to determine the prognostic value of low platelet reactivity (LPR), optimal platelet reactivity (OPR), or high platelet reactivity (HPR) by applying uniform cut-off values for standardized devices.
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              Transcatheter Aortic Valve Thrombosis: Incidence, Predisposing Factors, and Clinical Implications.

              There are limited data on the incidence, clinical implications, and predisposing factors of transcatheter heart valve (THV) thrombosis following transcatheter aortic valve replacement (TAVR).
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                Author and article information

                Journal
                J Clin Med
                J Clin Med
                jcm
                Journal of Clinical Medicine
                MDPI
                2077-0383
                12 April 2019
                April 2019
                : 8
                : 4
                Affiliations
                [1 ]Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67000 Strasbourg, France; charline.jimenez@ 123456chru-strasbourg.fr (C.J.); benjamin.marchandot@ 123456chru-strasbourg.fr (B.M.); marion.kibler@ 123456chru-strasbourg.fr (M.K.); adrien.carmona@ 123456chru-strasbourg.fr (A.C.); marilou.peillex@ 123456chru-strasbourg.fr (M.P.); joe.heger@ 123456chru-strasbourg.fr (J.H.); antonin.trimaille@ 123456chru-strasbourg.fr (A.T.); matsuken_22@ 123456yahoo.co.jp (K.M.); anne-claire.reydel@ 123456chru-strasbourg.fr (A.R.); sebastien.hess@ 123456chru-strasbourg.fr (S.H.); Laurence.JESEL-MOREL@ 123456chru-strasbourg.fr (L.J.); Patrick.Ohlmann@ 123456chru-strasbourg.fr (P.O.)
                [2 ]Université de Strasbourg, Département de Radiologie, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67000 Strasbourg, France; mickael.ohana@ 123456chru-strasbourg.fr
                [3 ]UMR INSERM 1260 Regenerative Nanomedicine, Université de Strasbourg, 67000 Strasbourg, France
                Author notes
                [* ]Correspondence: olivier.morel@ 123456chru-strasbourg.fr ; Tel.: +33-369550949
                Article
                jcm-08-00506
                10.3390/jcm8040506
                6518225
                31013785
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

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