Research paper| Volume 16, ISSUE 2, P168-173, March 2022

The impact of hypo-attenuated leaflet thickening on haemodynamic valve deterioration following transcatheter aortic valve replacement

Published:November 25, 2021DOI:



      Hypo-attenuated leaflet thickening (HALT) may occur following transcatheter aortic valve replacement (TAVR), however, it remains unclear if HALT is a predictor of haemodynamic valve deterioration (HVD).


      To determine the impact of HALT on the occurrence of HVD.


      We prospectively evaluated 186 patients for the presence of HALT at a median of 6 weeks following TAVR (Interquartile-range [IQR] 4–12 weeks). HALT depth and area were measured. HVD encompassed any of the following: mean gradient ≥20 ​mmHg with an increase in gradient ≥10 ​mmHg from baseline, Doppler velocity index reduction ≥0.1 or new moderate-to-severe valvular regurgitation. Routine echocardiograms at discharge, one month and annually, were assessed by echo-cardiologists that were blinded to the HALT status.


      LT prevalence was 17.7% (33/186). HVD was present in 8.6% (16/186) at a median follow-up of 2 years (IQR 1–3); two required valve re-intervention and five required anticoagulation. HALT was the only independent predictor of HVD on multivariate analysis (OR 33.3, 95%CI 7.4–125). Patients with HALT were more likely to develop HVD, require repeat valve intervention and have higher trans-valvular gradients at up to 3-year follow-up. Patients with HALT had a median cumulative thickness of 2.9 ​mm (IQR 1.9–4.7) and area of 64.2 ​mm2 (IQR 40.9–91.6). Thresholds for HALT in predicting HVD were a cumulative depth of 2.4 ​mm (Specificity 94.1%, Sensitivity 75.0%, AUC ​= ​0.87) and cumulative area of 28 ​mm2 (Specificity 92.2%, Sensitivity 81.3%, AUC ​= ​0.86).


      HALT is an independent predictor of HVD, which exhibits specific depth and area thresholds to predict HVD. CT following TAVR may determine patients at risk of HVD.

      Graphical abstract


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        • Mack M.J.
        • Leon M.B.
        • Thourani V.H.
        • et al.
        Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.
        N Engl J Med. 2019; 380: 1695-1705
        • Rashid H.N.
        • Gooley R.P.
        • Nerlekar N.
        • et al.
        Bioprosthetic aortic valve leaflet thrombosis detected by multidetector computed tomography is associated with adverse cerebrovascular events: a meta-analysis of observational studies.
        EuroIntervention. 2018; 13: e1748-e1755
        • Chakravarty T.
        • Sondergaard L.
        • Friedman J.
        • et al.
        Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study.
        Lancet. 2017; 389: 2383-2392
        • Makkar R.R.
        • Fontana G.
        • Jilaihawi H.
        • et al.
        Possible subclinical leaflet thrombosis in bioprosthetic aortic valves.
        N Engl J Med. 2015; 373: 2015-2024
        • Blanke P.
        • Leipsic J.A.
        • Popma J.J.
        • et al.
        Evolut low risk LTIS-sI. Leaflet thickening or immobility following aortic valve replacement: results from the Evolut low risk sub-study.
        J Am Coll Cardiol. 2020;
        • Makkar R.R.
        • Blanke P.
        • Leipsic J.
        • et al.
        Subclinical leaflet thrombosis in transcatheter and surgical bioprosthetic valves: PARTNER 3 cardiac computed tomography substudy.
        J Am Coll Cardiol. 2020; 75: 3003-3015
        • Hansson N.C.
        • Grove E.L.
        • Andersen H.R.
        • et al.
        Transcatheter aortic valve thrombosis: incidence, predisposing factors, and clinical implications.
        J Am Coll Cardiol. 2016; 68: 2059-2069
        • Midha P.A.
        • Raghav V.
        • Condado J.F.
        • et al.
        Valve type, size, and deployment location affect hemodynamics in an in vitro valve-in-valve model.
        JACC Cardiovasc Interv. 2016; 9: 1618-1628
        • Midha P.A.
        • Raghav V.
        • Sharma R.
        • et al.
        The fluid mechanics of transcatheter heart valve leaflet thrombosis in the neosinus.
        Circulation. 2017; 136: 1598-1609
        • Vahidkhah K.
        • Barakat M.
        • Abbasi M.
        • et al.
        Valve thrombosis following transcatheter aortic valve replacement: significance of blood stasis on the leaflets.
        Eur J Cardio Thorac Surg. 2017; 51: 927-935
        • Ducci A.
        • Pirisi F.
        • Tzamtzis S.
        • Burriesci G.
        Transcatheter aortic valves produce unphysiological flows which may contribute to thromboembolic events: an in-vitro study.
        J Biomech. 2016; 49: 4080-4089
        • Rashid H.N.
        • Gooley R.P.
        • Cameron J.D.
        Prosthesis geometrical factors in the development of hypo-attenuated leaflet thickening.
        J Am Coll Cardiol. 2020; 76: 1913-1914
        • Jilaihawi H.
        • Asch F.M.
        • Manasse E.
        • et al.
        Systematic CT methodology for the evaluation of subclinical leaflet thrombosis.
        JACC Cardiovasc Imag. 2017; 10: 461-470
        • Baumgartner H.
        • Falk V.
        • Bax J.J.
        • et al.
        2017 ESC/EACTS Guidelines for the management of valvular heart disease.
        Eur Heart J. 2017; 38: 2739-2791
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • et al.
        2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines.
        J Am Coll Cardiol. 2017; 70: 252-289
        • Brouwer J.
        • Nijenhuis V.J.
        • Delewi R.
        • et al.
        Aspirin with or without clopidogrel after transcatheter aortic-valve implantation.
        N Engl J Med. 2020;
        • Sondergaard L.
        • De Backer O.
        • Kofoed K.F.
        • et al.
        Natural history of subclinical leaflet thrombosis affecting motion in bioprosthetic aortic valves.
        Eur Heart J. 2017; 38: 2201-2207
        • Rashid H.N.
        • Michail M.
        • Ihdayhid A.R.
        • et al.
        Clinical predictors and sequelae of computed tomography defined leaflet thrombosis following transcatheter aortic valve replacement at medium-term follow-up.
        Heart Ves. 2021;
        • Blanke P.
        • Weir-McCall J.R.
        • Achenbach S.
        • et al.
        Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI)/Transcatheter aortic valve replacement (TAVR): an expert consensus document of the society of cardiovascular computed tomography.
        JACC Cardiovasc Imag. 2019; 12: 1-24
        • Varc-3 Writing C.
        • Genereux P.
        • Piazza N.
        • et al.
        Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research.
        Eur Heart J. 2021; 42: 1825-1857
        • Capodanno D.
        • Petronio A.S.
        • Prendergast B.
        • et al.
        Standardized definitions of structural deterioration and valve failure in assessing long-term durability of transcatheter and surgical aortic bioprosthetic valves: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) endorsed by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
        Eur Heart J. 2017; 38: 3382-3390
        • Durand E.
        • Sokoloff A.
        • Urena-Alcazar M.
        • et al.
        Assessment of long-term structural deterioration of transcatheter aortic bioprosthetic valves using the new European definition.
        Circ Cardiovasc Interv. 2019; 12e007597
        • Rheude T.
        • Pellegrini C.
        • Cassese S.
        • et al.
        Predictors of haemodynamic structural valve deterioration following transcatheter aortic valve implantation with latest-generation balloon-expandable valves.
        EuroIntervention. 2020; 15: 1233-1239
        • Popma J.J.
        • Deeb G.M.
        • Yakubov S.J.
        • et al.
        Evolut low risk trial I. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.
        N Engl J Med. 2019; 380: 1706-1715
        • Feldman T.E.
        • Reardon M.J.
        • Rajagopal V.
        • et al.
        Effect of mechanically expanded vs self-expanding transcatheter aortic valve replacement on mortality and major adverse clinical events in high-risk patients with aortic stenosis: the REPRISE III randomized clinical trial.
        J Am Med Assoc. 2018; 319: 27-37
        • Rashid H.N.
        • Brown A.J.
        • McCormick L.M.
        • et al.
        Subclinical leaflet thrombosis in transcatheter aortic valve replacement detected by multidetector computed tomography- A review of current evidence.
        Circ J. 2018;
        • Jose J.
        • Sulimov D.S.
        • El-Mawardy M.
        • et al.
        Clinical bioprosthetic heart valve thrombosis after transcatheter aortic valve replacement: incidence, characteristics, and treatment outcomes.
        JACC Cardiovasc Interv. 2017; 10: 686-697
        • Dangas G.D.
        • Tijssen J.G.P.
        • Wohrle J.
        • et al.
        A controlled trial of rivaroxaban after transcatheter aortic-valve replacement.
        N Engl J Med. 2019; 382: 120-129
        • Overtchouk P.
        • Guedeney P.
        • Rouanet S.
        • et al.
        Long-term mortality and early valve dysfunction according to anticoagulation use: the France TAVI registry.
        J Am Coll Cardiol. 2019; 73: 13-21
        • Herrmann H.C.
        • Daneshvar S.A.
        • Fonarow G.C.
        • et al.
        Prosthesis-patient mismatch in patients undergoing transcatheter aortic valve replacement: from the STS/ACC TVT registry.
        J Am Coll Cardiol. 2018; 72: 2701-2711
        • Rodes-Cabau J.
        • Pibarot P.
        • Suri R.M.
        • et al.
        Impact of aortic annulus size on valve hemodynamics and clinical outcomes after transcatheter and surgical aortic valve replacement: insights from the PARTNER Trial.
        Circ Cardiovasc Interv. 2014; 7: 701-711
        • Rashid Hashrul
        • Gooley Robert
        • McCormick Liam
        • et al.
        Safety and efficacy of valve repositioning during transcatheter aortic valve replacement with the Lotus Valve System.
        J Cardiol. 2017; 70: 55-61
        • Rashid Hashrul
        • Layland Jamie
        Association between device-related thrombus and the neo-appendage with left-atrial appendage occlusion devices.
        Eur Heart J. 2021; 42: 1047-1048
        • Khav Nancy
        • Rashid Hashrul
        • Brown Adam
        The role of four-dimensional computed tomography in transcatheter aortic valve replacement prosthesis endocarditis with concurrent leaflet thrombosis: a case report.
        Eur Heart J Case Rep. 2020; 4: 1-5
        • Rashid H.
        • Michail M.
        • Ihdayhid Abdul
        • et al.
        Prosthesis geometrical predictors of leaflet thrombosis following transcatheter aortic valve replacement with intra-annular prostheses.
        Heart, Lung Circul. 2022; (In press)
        • Rashid Hashrul
        • Rajani Ronak
        • Patterson Tiffany
        • et al.
        Computed tomography imaging for subclinical leaflet thrombosis following surgical and transcatheter aortic valve replacement.
        Heart, Lung Circul. 2022; (In press)
        • Rashid Hashrul
        • Cameron James
        • Gooley Robert
        Early bioprosthetic valve dysfunction following TAVR: Role of CT imaging in diagnosing acute leaflet thrombosis.
        Heart, Lung Circul. 2022; (In press)