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Background Transcatheter aortic valve replacement (TAVR) is becoming increasingly utilized for the treatment of severe aortic valvular heart disease. Infective endocarditis of TAVR is rare but associated with higher mortality and morbidity. The potential for leaflet thrombosis following TAVR is also becoming increasingly recognized. Diagnosis of these conditions on echocardiography can be challenging due to prosthesis artefact. Case summary An 84-year-old man with a previous transcatheter aortic valve replacement presented with a febrile illness and bacteraemia. Transthoracic and transoesophageal echocardiography demonstrated high transvalvular gradients with features of prosthesis endocarditis, though leaflet morphology could not be fully assessed due to prosthesis artefact. Four-dimensional computed tomography revealed hypo-attenuated leaflet thickening with reduced leaflet motion, consistent with prosthesis leaflet thrombosis. The patient was successfully treated with antibiotics and anticoagulation, with resolution of the infection and normalization of the transvalvular gradient after 6 weeks. Discussion Echocardiography should be the first-line investigation for assessing leaflet morphology in suspected prosthetic valve endocarditis or leaflet thrombosis but its accuracy may be limited by artefact. Our case highlights that fourdimensional computed tomography provides further evaluation of prosthesis leaflet morphology/motion, providing valuable diagnostic information.Copyright © The Author(s) 2020.

Background: Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Method(s): Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Result(s): Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51+/-11 and 51+/-10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in

Background: The clinical predictors and sequelae of leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is still unclear. Therefore, our aim was to determine the clinical predictors and sequelae at mid-term follow-up of computed tomography (CT)-defined LT following TAVR. Methods and Results: We performed a prospective evaluation with a 320-multislice CT following TAVR for the presence of LT, defined as hypo-attenuated leaflet thickening (HALT). Four-dimensional CT image-rendering was performed to determine the presence of reduced leaflet motion (RELM). 172 patients [89 (51.7%) male, mean age 82.8 +/- 5.7 years] treated with commercially available TAVR device (Lotus 54%, CoreValve 32% and Sapien 3 14%) were included, with median CT-scan at 6.0 weeks post-TAVR. Prevalence of HALT was 14.0% (24 cases) and RELM was 9.8% (17 cases). On multivariate analysis, patients with HALT were less prescribed oral anticoagulation (OAC) (OR 9.9), received larger TAVR prostheses (OR 5.7) and higher rates of moderate-severe para-valvular regurgitation (PVR) (OR 16.3). There was no difference in clinical outcomes at a median follow-up of 2.3 years. Patients with RELM had significantly higher transvalvular gradients after discharge when compared to those without RELM. Conclusion(s): Absence of OAC, large TAVR prostheses and moderate-severe PVR were predictors for LT. Transvalvular gradients were higher in patients that developed RELM but not HALT. Further studies are warranted to determine the long-term impact of LT on TAVR durability. Graphic abstract: Prevalence of different sub-types of CT-defined LT (HALT and RELM) and the clinical predictors of developing LT following TAVR. CT computed tomography, HALT hypo-attenuated leaflet thickening, LT leaflet thrombosis, RELM reduced leaflet motion, TAVR transcatheter aortic valve replacement [Figure not available: see fulltext.].Copyright © 2021, Crown.

Background: 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). Aim(s): To determine the impact of HALT on the occurrence of HVD. Method(s): 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. Result(s): 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). Conclusion(s): 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.Copyright © 2021

Background: Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Method(s): Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Result(s): Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51+/-11 and 51+/-10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in

Background: The clinical predictors and sequelae of leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is still unclear. Therefore, our aim was to determine the clinical predictors and sequelae at mid-term follow-up of computed tomography (CT)-defined LT following TAVR. Methods and Results: We performed a prospective evaluation with a 320-multislice CT following TAVR for the presence of LT, defined as hypo-attenuated leaflet thickening (HALT). Four-dimensional CT image-rendering was performed to determine the presence of reduced leaflet motion (RELM). 172 patients [89 (51.7%) male, mean age 82.8 +/- 5.7 years] treated with commercially available TAVR device (Lotus 54%, CoreValve 32% and Sapien 3 14%) were included, with median CT-scan at 6.0 weeks post-TAVR. Prevalence of HALT was 14.0% (24 cases) and RELM was 9.8% (17 cases). On multivariate analysis, patients with HALT were less prescribed oral anticoagulation (OAC) (OR 9.9), received larger TAVR prostheses (OR 5.7) and higher rates of moderate-severe para-valvular regurgitation (PVR) (OR 16.3). There was no difference in clinical outcomes at a median follow-up of 2.3 years. Patients with RELM had significantly higher transvalvular gradients after discharge when compared to those without RELM. Conclusion(s): Absence of OAC, large TAVR prostheses and moderate-severe PVR were predictors for LT. Transvalvular gradients were higher in patients that developed RELM but not HALT. Further studies are warranted to determine the long-term impact of LT on TAVR durability. Graphic abstract: Prevalence of different sub-types of CT-defined LT (HALT and RELM) and the clinical predictors of developing LT following TAVR. CT computed tomography, HALT hypo-attenuated leaflet thickening, LT leaflet thrombosis, RELM reduced leaflet motion, TAVR transcatheter aortic valve replacement [Figure not available: see fulltext.].Copyright © 2021, Crown.

Background Transcatheter aortic valve replacement (TAVR) is becoming increasingly utilized for the treatment of severe aortic valvular heart disease. Infective endocarditis of TAVR is rare but associated with higher mortality and morbidity. The potential for leaflet thrombosis following TAVR is also becoming increasingly recognized. Diagnosis of these conditions on echocardiography can be challenging due to prosthesis artefact. Case summary An 84-year-old man with a previous transcatheter aortic valve replacement presented with a febrile illness and bacteraemia. Transthoracic and transoesophageal echocardiography demonstrated high transvalvular gradients with features of prosthesis endocarditis, though leaflet morphology could not be fully assessed due to prosthesis artefact. Four-dimensional computed tomography revealed hypo-attenuated leaflet thickening with reduced leaflet motion, consistent with prosthesis leaflet thrombosis. The patient was successfully treated with antibiotics and anticoagulation, with resolution of the infection and normalization of the transvalvular gradient after 6 weeks. Discussion Echocardiography should be the first-line investigation for assessing leaflet morphology in suspected prosthetic valve endocarditis or leaflet thrombosis but its accuracy may be limited by artefact. Our case highlights that fourdimensional computed tomography provides further evaluation of prosthesis leaflet morphology/motion, providing valuable diagnostic information.Copyright © The Author(s) 2020.

Background: 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). Aim(s): To determine the impact of HALT on the occurrence of HVD. Method(s): 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. Result(s): 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). Conclusion(s): 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.Copyright © 2021

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72+/-33mL to 89+/-43mL, p<0.001) and mean EATd decreased (baseline -76+/-6 HU vs. -86+/-5 HU, p<0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72+/-33mL to 89+/-43mL, p<0.001) and mean EATd decreased (baseline -76+/-6 HU vs. -86+/-5 HU, p<0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Background: Familial hypercholesterolemia (FH) is a common underdiagnosed autosomal dominant lipid disorder carrying a significant risk of premature coronary artery disease. The aim of this study was to evaluate the awareness and knowledge of heterozygous FH of healthcare providers in coronary care units (CCUs). Method(s): Medical staff working in CCUs in 4 sizable metropolitan health networks in Melbourne, Australia, were requested to complete a structured anonymised questionnaire with regard to FH. The results were tabulated and analysed with the Statistical Package for the Social Sciences version 23 (IBM, New York, NY). Result(s): A total of 121 participants (67% response rate) completed the survey. Some 76% claimed to be at least modestly familiar with FH, and more than half of them adequately described FH; however, only 16% and 43%, respectively, were aware of the prevalence of FH and existence of lipid guidelines. In regard to epidemiological knowledge and update in the management of FH in CCUs, knowledge was suboptimal. In regard to FH care, General Practitioners were rated by 72% of participants as the first most efficient healthcare provider in the management of FH, and cardiologists were rated by 54% of participants as the second most efficient healthcare provider in the management of FH. Some 36% of respondents advocated a form of alert system in laboratory reports to facilitate the diagnosis of FH. Conclusion(s): This survey identified substantial gaps in the knowledge and awareness of FH among healthcare providers involved in the management of acute coronary syndrome. Focused education and clinical training are warranted to raise awareness of FH among healthcare providers working in CCUs.Copyright © 2019

Background: Antithrombotic recommendations following transcatheter aortic valve replacement (TAVR) are largely based on previous trial protocols. The efficacy and risk of anticoagulation has not been systematically assessed. The aim of this study was to determine the efficacy and safety of oral anticoagulation in patients with atrial fibrillation (AF) following TAVR with the Lotus Valve System (Boston Scientific, Marlborough, MA, USA). Method(s): Consecutive patients with severe aortic stenosis who underwent Lotus valve implantation were prospectively recruited (n = 164). Atrial fibrillation patients prescribed oral anticoagulation (standard AF therapy) were compared to non-AF patients prescribed aspirin and clopidogrel (standard non-AF therapy). Twenty (20) of 164 patients were excluded, as they were not prescribed standard therapy. The primary endpoint was 6-month incidence of death, myocardial infarction, stroke/transient ischaemic attack (TIA) or major/life-threatening bleeding. Secondary endpoints included each component of the primary endpoint, defined according to VARC-2. Result(s): Overall, the primary endpoint occurred in 20.8% and 17.7% of the standard AF and standard non-AF therapy groups respectively (p = 0.82). There was no statistically significant difference in bleeding (12.5% versus 9.4%, p = 0.77) or stroke/TIA (2.1% versus 8.3%, p = 0.27) between the standard AF and standard non-AF therapy groups respectively. Conclusion(s): This study supports the safety of anticoagulation in AF patients, which did not result in excess risk of bleeding or stroke/TIA compared with dual antiplatelet therapy in non-AF patients.Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background: Familial hypercholesterolemia (FH) is a common underdiagnosed autosomal dominant lipid disorder carrying a significant risk of premature coronary artery disease. The aim of this study was to evaluate the awareness and knowledge of heterozygous FH of healthcare providers in coronary care units (CCUs). Method(s): Medical staff working in CCUs in 4 sizable metropolitan health networks in Melbourne, Australia, were requested to complete a structured anonymised questionnaire with regard to FH. The results were tabulated and analysed with the Statistical Package for the Social Sciences version 23 (IBM, New York, NY). Result(s): A total of 121 participants (67% response rate) completed the survey. Some 76% claimed to be at least modestly familiar with FH, and more than half of them adequately described FH; however, only 16% and 43%, respectively, were aware of the prevalence of FH and existence of lipid guidelines. In regard to epidemiological knowledge and update in the management of FH in CCUs, knowledge was suboptimal. In regard to FH care, General Practitioners were rated by 72% of participants as the first most efficient healthcare provider in the management of FH, and cardiologists were rated by 54% of participants as the second most efficient healthcare provider in the management of FH. Some 36% of respondents advocated a form of alert system in laboratory reports to facilitate the diagnosis of FH. Conclusion(s): This survey identified substantial gaps in the knowledge and awareness of FH among healthcare providers involved in the management of acute coronary syndrome. Focused education and clinical training are warranted to raise awareness of FH among healthcare providers working in CCUs.Copyright © 2019

Background: Antithrombotic recommendations following transcatheter aortic valve replacement (TAVR) are largely based on previous trial protocols. The efficacy and risk of anticoagulation has not been systematically assessed. The aim of this study was to determine the efficacy and safety of oral anticoagulation in patients with atrial fibrillation (AF) following TAVR with the Lotus Valve System (Boston Scientific, Marlborough, MA, USA). Method(s): Consecutive patients with severe aortic stenosis who underwent Lotus valve implantation were prospectively recruited (n = 164). Atrial fibrillation patients prescribed oral anticoagulation (standard AF therapy) were compared to non-AF patients prescribed aspirin and clopidogrel (standard non-AF therapy). Twenty (20) of 164 patients were excluded, as they were not prescribed standard therapy. The primary endpoint was 6-month incidence of death, myocardial infarction, stroke/transient ischaemic attack (TIA) or major/life-threatening bleeding. Secondary endpoints included each component of the primary endpoint, defined according to VARC-2. Result(s): Overall, the primary endpoint occurred in 20.8% and 17.7% of the standard AF and standard non-AF therapy groups respectively (p = 0.82). There was no statistically significant difference in bleeding (12.5% versus 9.4%, p = 0.77) or stroke/TIA (2.1% versus 8.3%, p = 0.27) between the standard AF and standard non-AF therapy groups respectively. Conclusion(s): This study supports the safety of anticoagulation in AF patients, which did not result in excess risk of bleeding or stroke/TIA compared with dual antiplatelet therapy in non-AF patients.Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Objective: To determine the effect of aorto-ventricular angulation (AA) on procedural success with the Lotus Valve system. Background(s): AA, the angulation of the aortic valve basal plane, may affect the deployment of transcatheter aortic valve replacements (TAVRs). The Lotus Valve system is fully repositionable and delivered on a pre-shaped catheter which may alter the impact of AA on its deployment. The effect of AA on procedural and clinical outcomes with the Lotus valve is unreported. Method(s): Consecutive patients who underwent transfemoral TAVR with the Lotus Valve system were analyzed. AA was determined on pre-procedural multi-detector computed tomography imaging. Device success, procedural characteristics, and clinical events were assessed according to Valve Academic Research Consortium-2 (VARC2) definitions. Result(s): One hundred sixty-five patients were analyzed (48% male, mean age 84 years). The mean AA was 47.8 degrees. Patients were, therefore, divided into low AA (AA < 48degree) or high AA (AA >= 48degree). Baseline characteristics were similar in both cohorts. Device success and procedural outcomes were also similar including procedure time, contrast dose, and need to reposition. There was no difference in degree of moderate or greater para-valvular regurgitation (PVR) (0% vs. 3%, P = 0.09). Clinical outcomes of death, stroke, myocardial infarction, and other major VARC2 endpoints were similar. Conclusion(s): AA did not affect device success or clinical outcome with the Lotus Valve system. The Lotus' unique design features may have mitigated the impact of AA by improving the accuracy, ease of valve positioning, and reducing PVR.Copyright © 2017 Wiley Periodicals, Inc.

Aims: Leaflet thrombosis (LT) has become increasingly recognised following transcatheter and surgical aortic bioprosthetic valve (ABV) replacement and can be reliably identified by multidetector computed tomography (MDCT). However, it is an ongoing debate whether MDCT-defined LT is associated with adverse cerebrovascular outcomes. We sought to perform a systematic review and meta-analysis in order to assess the incidence and clinical outcomes associated with MDCT-defined leaflet thrombosis following (ABV) replacement. Methods and Results: Electronic databases were searched for studies that performed mandatory MDCT imaging following ABV replacement. The primary endpoint was the incidence of cerebrovascular events, defined as a composite of stroke or transient ischaemic attack (TIA). Secondary endpoints included major adverse cerebrovascular and cardiovascular events (MACCE), stroke, TIA, death or myocardial infarction. In total, six studies met the inclusion criteria with 11.6% (198/1,704) of patients having MDCT-defined LT. The prevalence of LT following transcatheter and surgical ABV replacement was 13.2% and 3.6%, respectively. Cerebrovascular events were significantly increased in patients with LT (odds ratio [OR] 3.38, 95% CI: 1.78-6.41, p<0.001). The risk of MACCE (OR 2.10, 95% CI: 1.21-3.64, p<0.001) and TIA (OR 5.86, 95% CI: 2.05-16.75, p<0.001) was also increased in patients with LT, although there were no differences in the incidence of stroke (OR 2.43, 95% CI: 1.00-5.93, p=0.05), death (OR 0.92, 95% CI: 0.42-2.03, p=0.84) or myocardial infarction (OR 1.72, 95% CI: 0.34-9.78, p=0.54) between groups. Conclusion(s): MDCT-defined LT following ABV replacement is associated with a significantly increased risk of adverse cerebrovascular events. Further prospective studies are required to ascertain whether LT can be prevented or treated with pharmacological strategies.Copyright © Europa Digital & Publishing 2018. All rights reserved.

Subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement (TAVR) has been increasingly recognized. SLT has the hallmark features of hypo-attenuated leaflet thickening (HALT) on multidetector computed tomography (MDCT), which may result in hypoattenuation affecting motion (HAM). The actual prevalence of this condition is uncertain, with limited observational registries. SLT has caught the attention of the cardiovascular community because of concerns regarding its clinical sequelae, specifically the potential increased incidence of cerebrovascular events. There are available, albeit sparse, data to suggest that when left untreated, SLT may lead to valve deterioration with potential hemodynamic compromise and potentially clinically overt prostheses thrombosis. Some clinicians have opted to treat patients with SLT with anticoagulation. Although anticoagulation may be a rational treatment option, little data exist on the safety and efficacy of this treatment. This is particularly important considering TAVR patients also have higher bleeding risk than the standard population. In this review, we aim to summarize the current evidence on SLT, explore its pathophysiological mechanism, discuss the current treatment options and future trials that may clarify the optimal antithrombotic strategies of SLT.Copyright © 2018, Japanese Circulation Society. All rights reserved.

Objective: To determine the effect of aorto-ventricular angulation (AA) on procedural success with the Lotus Valve system. Background(s): AA, the angulation of the aortic valve basal plane, may affect the deployment of transcatheter aortic valve replacements (TAVRs). The Lotus Valve system is fully repositionable and delivered on a pre-shaped catheter which may alter the impact of AA on its deployment. The effect of AA on procedural and clinical outcomes with the Lotus valve is unreported. Method(s): Consecutive patients who underwent transfemoral TAVR with the Lotus Valve system were analyzed. AA was determined on pre-procedural multi-detector computed tomography imaging. Device success, procedural characteristics, and clinical events were assessed according to Valve Academic Research Consortium-2 (VARC2) definitions. Result(s): One hundred sixty-five patients were analyzed (48% male, mean age 84 years). The mean AA was 47.8 degrees. Patients were, therefore, divided into low AA (AA < 48degree) or high AA (AA >= 48degree). Baseline characteristics were similar in both cohorts. Device success and procedural outcomes were also similar including procedure time, contrast dose, and need to reposition. There was no difference in degree of moderate or greater para-valvular regurgitation (PVR) (0% vs. 3%, P = 0.09). Clinical outcomes of death, stroke, myocardial infarction, and other major VARC2 endpoints were similar. Conclusion(s): AA did not affect device success or clinical outcome with the Lotus Valve system. The Lotus' unique design features may have mitigated the impact of AA by improving the accuracy, ease of valve positioning, and reducing PVR.Copyright © 2017 Wiley Periodicals, Inc.

Aims: Leaflet thrombosis (LT) has become increasingly recognised following transcatheter and surgical aortic bioprosthetic valve (ABV) replacement and can be reliably identified by multidetector computed tomography (MDCT). However, it is an ongoing debate whether MDCT-defined LT is associated with adverse cerebrovascular outcomes. We sought to perform a systematic review and meta-analysis in order to assess the incidence and clinical outcomes associated with MDCT-defined leaflet thrombosis following (ABV) replacement. Methods and Results: Electronic databases were searched for studies that performed mandatory MDCT imaging following ABV replacement. The primary endpoint was the incidence of cerebrovascular events, defined as a composite of stroke or transient ischaemic attack (TIA). Secondary endpoints included major adverse cerebrovascular and cardiovascular events (MACCE), stroke, TIA, death or myocardial infarction. In total, six studies met the inclusion criteria with 11.6% (198/1,704) of patients having MDCT-defined LT. The prevalence of LT following transcatheter and surgical ABV replacement was 13.2% and 3.6%, respectively. Cerebrovascular events were significantly increased in patients with LT (odds ratio [OR] 3.38, 95% CI: 1.78-6.41, p<0.001). The risk of MACCE (OR 2.10, 95% CI: 1.21-3.64, p<0.001) and TIA (OR 5.86, 95% CI: 2.05-16.75, p<0.001) was also increased in patients with LT, although there were no differences in the incidence of stroke (OR 2.43, 95% CI: 1.00-5.93, p=0.05), death (OR 0.92, 95% CI: 0.42-2.03, p=0.84) or myocardial infarction (OR 1.72, 95% CI: 0.34-9.78, p=0.54) between groups. Conclusion(s): MDCT-defined LT following ABV replacement is associated with a significantly increased risk of adverse cerebrovascular events. Further prospective studies are required to ascertain whether LT can be prevented or treated with pharmacological strategies.Copyright © Europa Digital & Publishing 2018. All rights reserved.

Subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement (TAVR) has been increasingly recognized. SLT has the hallmark features of hypo-attenuated leaflet thickening (HALT) on multidetector computed tomography (MDCT), which may result in hypoattenuation affecting motion (HAM). The actual prevalence of this condition is uncertain, with limited observational registries. SLT has caught the attention of the cardiovascular community because of concerns regarding its clinical sequelae, specifically the potential increased incidence of cerebrovascular events. There are available, albeit sparse, data to suggest that when left untreated, SLT may lead to valve deterioration with potential hemodynamic compromise and potentially clinically overt prostheses thrombosis. Some clinicians have opted to treat patients with SLT with anticoagulation. Although anticoagulation may be a rational treatment option, little data exist on the safety and efficacy of this treatment. This is particularly important considering TAVR patients also have higher bleeding risk than the standard population. In this review, we aim to summarize the current evidence on SLT, explore its pathophysiological mechanism, discuss the current treatment options and future trials that may clarify the optimal antithrombotic strategies of SLT.Copyright © 2018, Japanese Circulation Society. All rights reserved.

Introduction: Leaflet thrombosis (LT) defined by computed tomography (CT) following transcatheter aortic valve replacement (TAVR) has been shown to increase cerebrovascular events. The neo-sinus plays an important role in the development of LT. Intra-annular valves (IAV) have a larger neo-sinus when compared to supra-annular valves (SAV), and has been associated with larger thrombus burden. The prevalence of LT with IAV and SAV in a larger, diverse cohort is unknown. Method(s): We performed a systematic review to assess the prevalence of LT in IAV versus SAV TAVR prostheses. Inclusion criteria were (1) reported CT-defined LT following TAVR, (2) comparison between LT and non-LT cohort, (3) separate registry/database, and (4) fully published status. A total of 2,013 citations were reviewed and 7 studies were included. Result(s): Overall, 1,644 patients were included from 7 observational studies and the prevalence of LT following TAVR was 12.8%. The Portico valve system (IAV) had the highest prevalence of LT with 35.2%, followed by Symetis Acurate Neo (SAV) at 15.4% and the Lotus valve system (IAV) at 14.5%. LT occurred more frequently in IAV than SAV (13.5% vs. 7%, P = 0.02). Subanalysis of IAV versus SAV with the exclusion of the Portico valve was performed to ensure results were not influenced by this valve system and revealed IAV still had higher rates of LT (12.1% vs. 7%, P = 0.05). Conclusion(s): In summary, IAV prostheses appear to be associated with higher rates of LT when compared with SAV.Copyright © 2018 Wiley Periodicals, Inc.

A 79-year-old man with stable chronic obstructive pulmonary disease was found to have an abdominal aortic aneurysm and worsening dyspnoea. Echocardiography demonstrated critical aortic stenosis. Simultaneous endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR) was recommended due to high surgical risk. Procedural strategy was to perform balloon valvuloplasty (BAV), followed by EVAR then TAVR. The initial 25 mm Lotus valve adopted a barrel shape suggestive of an undersized valve and was thus replaced with a 27 mm valve. Post procedural echo revealed no regurgitation. We report here for the first time a successful simultaneous TAVR/EVAR using the fully retrievable Lotus Valve.Copyright © 2016, Japanese Association of Cardiovascular Intervention and Therapeutics.

A 79-year-old man with stable chronic obstructive pulmonary disease was found to have an abdominal aortic aneurysm and worsening dyspnoea. Echocardiography demonstrated critical aortic stenosis. Simultaneous endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR) was recommended due to high surgical risk. Procedural strategy was to perform balloon valvuloplasty (BAV), followed by EVAR then TAVR. The initial 25 mm Lotus valve adopted a barrel shape suggestive of an undersized valve and was thus replaced with a 27 mm valve. Post procedural echo revealed no regurgitation. We report here for the first time a successful simultaneous TAVR/EVAR using the fully retrievable Lotus Valve.Copyright © 2016, Japanese Association of Cardiovascular Intervention and Therapeutics.