The Aortic Prosthesis and Aortic Valve Bioprosthesis Trombosis as a Late Complication in Patients after the Bentall Procedure Followed by a Valve-in-Valve Transcatheter Aortic Valve Implantation

TL;DR

This paper reports a case where a patient developed a rare complication of aortic graft and valve thrombosis after a combined surgical and transcatheter valve procedure, successfully treated with blood thinners.

Contribution

The paper highlights thrombosis as a late complication following ViV-TAVI and demonstrates effective management with vitamin K antagonists.

Findings

Thrombosis of the aortic graft and valve occurred after ViV-TAVI and was partially resolved with LMWH and fully resolved with VKAs.

CT imaging was crucial in diagnosing thrombosis and assessing treatment response.

Multidisciplinary management avoided unnecessary invasive procedures and focused on anticoagulation therapy.

Abstract

Background: Valve-in-Valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a viable therapeutic option for structural valve degeneration following surgical aortic valve replacement (SAVR) or prior TAVI. However, the understanding of long-term complications and their management remains limited. Case presentation: We present the case of a 69-year-old male with a history of ViV-TAVI, who presented with symptoms of non-ST elevation myocardial infarction (NSTEMI) and transient ischemic attack (TIA). Computed tomography (CT) revealed thrombosis of the ascending aortic graft and aortic valve prosthesis. Transthoracic echocardiography (TTE) further confirmed new valve dysfunction, indicated by an increase in the aortic valve mean gradient. Treatment with low-molecular-weight heparin (LMWH) resulted in partial thrombus resolution. The multidisciplinary Heart Team opted against coronary angiography and recommended the long-term administration of vitamin K antagonists (VKAs). Follow-up CT showed the complete resolution of the thrombus. Conclusions: Thrombosis of the aortic graft and aortic valve following ViV-TAVI may be attributed to alterations in blood flow or mechanical manipulations during the TAVI procedure, yet it can be effectively managed with VKA therapy. CT is a valuable tool in coronary assessment in patients with NSTEMI and aortic valve and/or aortic graft thrombosis.

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Summary

Aortic graft thrombosis is an extremely rare complication in patients after ViV-TAVI, which may be caused by neointima rupture and can be successfully treated with anticoagulation. The angio-CT may be the alternative for coronary artery assessment in patients with NSTEMI in the presence of aortic graft and valve thrombosis.