Journal of Cardiovascular Computed Tomography xxx (2016) 1e2
Contents lists available at ScienceDirect
Journal of Cardiovascular Computed Tomography journal homepage: www.JournalofCardiovascularCT.com
Editorial
President's Page
We wait until Pandora's box is opened before we say, “Wow, maybe we should understand what's in that box.” This is the story of humans on every problem Peter Singer (Australian moral philosopher). Transcatheter aortic valve replacement has transformed the management of severe symptomatic aortic stenosis and cardiac CT has asserted itself as the primary modality for the screening and work up prior to the procedure. The integration of CT has allowed for improvement in clinical outcomes across transcatheter heart valve platforms through the reduction in paravalvular regurgitation, vascular access injury, annular rupture and coronary occlusion.1e5 While the role of CT prior to TAVR is well established the role post implantation is more nebulous. On past-generation CT scanners our group and others have used CT post implantation to better understand device deployment and positioning.6 More recently, as CT scanner technology has advanced the temporal and spatial resolution improvements have resulted in the identification of subclinical leaflet thickening/thrombosis. Importantly, these findings are commonly occult on other imaging studies such as echocardiography. These findings, in the early post-implantation period, in anywhere from 5e40% (in the Portico IDE Trial) of patients has both surprised and troubled the TAVR community broadly. The first report on transcatheter heart valve leaflet thickening evaluation in a consecutive cohort of patient was published by Bjarne Norgaard's group in Aarhus Denmark.7 They reported post-TAVI MDCT identified THV thrombosis as low-attenuation masses attached to THV cusps and was clearly distinctive from the leaflet tissue itself in 4% of patients. Only one of their cases was visible with TTE and they go further to suggest that MDCT with its excellent contrast and spatial resolution seems to provide the necessary detail to detect thrombus superior even to TOE. In the paper by Pache,8 the overall incidence of leaflet thickening was 10.3%. Importantly, none of the patients showed clinical symptoms and the postimplant gradients were no different than those without leaflet thickening. Post-interventional mean pressure gradients were also comparable between patients with and without leaflet thickening. Makkar and colleagues9 reported leaflet thickening and reduced leaflet motion in 17 of 132 patients (13%) although this did range up to 40% with some transcatheter devices. Interestingly, their registry included both transcatheter and surgical aortic bioprostheses with a similar incidence of such findings between them. While these findings are striking and, in fact, somewhat
sobering they need to be taken in the context of established clinical thrombosis rates of
Contents lists available at ScienceDirect
Journal of Cardiovascular Computed Tomography journal homepage: www.JournalofCardiovascularCT.com
Editorial
President's Page
We wait until Pandora's box is opened before we say, “Wow, maybe we should understand what's in that box.” This is the story of humans on every problem Peter Singer (Australian moral philosopher). Transcatheter aortic valve replacement has transformed the management of severe symptomatic aortic stenosis and cardiac CT has asserted itself as the primary modality for the screening and work up prior to the procedure. The integration of CT has allowed for improvement in clinical outcomes across transcatheter heart valve platforms through the reduction in paravalvular regurgitation, vascular access injury, annular rupture and coronary occlusion.1e5 While the role of CT prior to TAVR is well established the role post implantation is more nebulous. On past-generation CT scanners our group and others have used CT post implantation to better understand device deployment and positioning.6 More recently, as CT scanner technology has advanced the temporal and spatial resolution improvements have resulted in the identification of subclinical leaflet thickening/thrombosis. Importantly, these findings are commonly occult on other imaging studies such as echocardiography. These findings, in the early post-implantation period, in anywhere from 5e40% (in the Portico IDE Trial) of patients has both surprised and troubled the TAVR community broadly. The first report on transcatheter heart valve leaflet thickening evaluation in a consecutive cohort of patient was published by Bjarne Norgaard's group in Aarhus Denmark.7 They reported post-TAVI MDCT identified THV thrombosis as low-attenuation masses attached to THV cusps and was clearly distinctive from the leaflet tissue itself in 4% of patients. Only one of their cases was visible with TTE and they go further to suggest that MDCT with its excellent contrast and spatial resolution seems to provide the necessary detail to detect thrombus superior even to TOE. In the paper by Pache,8 the overall incidence of leaflet thickening was 10.3%. Importantly, none of the patients showed clinical symptoms and the postimplant gradients were no different than those without leaflet thickening. Post-interventional mean pressure gradients were also comparable between patients with and without leaflet thickening. Makkar and colleagues9 reported leaflet thickening and reduced leaflet motion in 17 of 132 patients (13%) although this did range up to 40% with some transcatheter devices. Interestingly, their registry included both transcatheter and surgical aortic bioprostheses with a similar incidence of such findings between them. While these findings are striking and, in fact, somewhat
sobering they need to be taken in the context of established clinical thrombosis rates of
