Jimenez Charline, Ohana Mickaël, Marchandot Benjamin, Kibler Marion, Carmona Adrien, Peillex Marilou, Heger Joe, Trimaille Antonin, Matsushita Kensuke, Reydel Antje, Hess Sébastien, Jesel Laurence, Ohlmann Patrick, Morel Olivier
Université de Strasbourg, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67000 Strasbourg, France.
Université de Strasbourg, Département de Radiologie, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, 67000 Strasbourg, France.
J Clin Med. 2019 Apr 12;8(4):506. doi: 10.3390/jcm8040506.
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 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 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); = 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.
经导管主动脉瓣置换术（TAVR）后，抗血栓治疗方案和血小板抑制程度对心脏多排计算机断层扫描（MDCT）检测到的亚临床瓣叶血栓形成（SLT）的影响尚未明确。影响运动的低密度影（HAM）已被提议作为SLT的替代标志物，其特征为瓣叶低密度增厚（HALT）和瓣叶运动同时减少（RELM）。我们旨在研究：（i）MDCT检测到的TAVR后HAM和HALT的发生率；（ii）SLT的预测因素；（iii）口服抗凝剂（OAC）以及通过血小板反应性指数血管扩张剂刺激磷蛋白（PRI-VASP）和二磷酸腺苷封闭时间（CT-ADP）评估的血小板抑制程度对SLT的影响。在2017年8月1日至2018年3月31日连续接受TAVR的187例患者中，90例在相关随访时进行了心脏CT检查。收集TAVR术前、出院时及术后1年的临床、生物学、超声心动图、手术特征和治疗情况。使用血小板PRI-VASP和CT-ADP即时检测法研究P2Y血小板抑制程度和原发性止血障碍。90例TAVR术后CT中有85例图像清晰，诊断质量足够并进行了评估。13例患者（15.3%）出现HAM，30例患者（35%）出现HALT。各组间手术特征，包括主动脉瓣钙化评分、瓣环大小或术中肝素治疗方案均无差异。同样，未发现P2Y抑制（PRI-VASP）和原发性止血障碍（CT-ADP）对SLT有影响。在12个月的随访中，未发现SLT对经胸超声心动图（TTE）评估的瓣膜恶化和临床事件有影响。多因素分析显示，出院时未进行口服抗凝治疗（HR 12.130，95%CI（1.394 - 150.582）；P = 0.028）和较高的血红蛋白水平是SLT的唯一独立预测因素。在4例出现HAM的患者中，开始OAC治疗后进行MDCT随访，结果显示HAM完全消退。在接受TAVR治疗的相当一部分患者中发现了SLT，其主要由未进行口服抗凝治疗决定。相反，未发现血小板抑制程度对SLT有影响。
