For the treatment of transcatheter aortic valve (TAV) thrombosis, both in its more common form of subclinical leaflet thrombosis (SLT) and the rarer clinical valve thrombosis (CVT), pharmacotherapy with vitamin K antagonists (VKA), non-vitamin K oral anticoagulants (NOAC) and an ultraslow, low-dose infusion of thrombolytics should be considered as treatment of first choice, according to a recent JACC review topic of the week.  

Rik Adrichem, MD, et. al, describe the continuum from SLT, affecting 10-20% of patients following TAVR, to CVT, affecting 1.2% and associated with bioprosthetic valve failure, neurologic or thromboembolic events, heart failure, and death. This continuum can be quantified by two current methods: grading (Grade 1-4) on a percentage of how much an affected leaflet has been thickened, called hypoattenuated leaflet thickening (HALT), or how much the leaflet’s motion has been reduced (reduced leaflet motion – RLM).  

The authors incorporate these two components into a diagnostic algorithm utilizing multislice computed tomography and transthoracic echocardiograms, as well as a treatment algorithm transitioning from antiplatelets to NOAC, NOAC to VKA, and VKA to possible single antiplatelet therapy based on patient response.  

They complement their work with a review of case studies involving different types of pharmacotherapies and a series of case vignettes addressing TAV thrombosis that led to promising clinical outcomes.   

The review concludes with an acknowledgement that there is more work to be done: “Further research is required to determine the optimal antithrombotic regimen after TAVR, unravel the clinical implications of SLT and define the best treatment algorithms of CVT.” 

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Computed Tomography, Nuclear Imaging

Keywords: Heart Failure, Thromboembolism, Thrombosis, Multidetector Computed Tomography, Platelet Aggregation Inhibitors, Anticoagulants, Transcatheter Aortic Valve Replacement, Aortic Valve