A matter of thrombosis: Different thrombus-like formations in balloon-expandable transcatheter aortic valve prostheses

OBJECTIVES: Transcatheter aortic valve implantation is a treatment strategy for degenerated aortic valve prostheses, but there is some concern regarding valve thrombosis. The optimal anticoagulation strategy for implantation of a transcatheter aortic valve prosthesis remains unclear. METHODS: Aortic root models with the Sapien-XT and S3 prostheses (sizes 23 and 26) fixed in a Perimount Magna Ease bioprosthesis (sizes 23 and 25) were constructed. The haemodynamics of the left ventricle were imitated in a proved in vitro model. Milk was used for coagulation after 90s. Different areas of the leaflets (W: wall coagulation, C: commissure coagulation left/right and S: sinus coagulation) were examined and the number of thrombus-like formations was counted. RESULTS: A total of 54% of the thrombus-like formations were found in the sinus, 28% at the wall area, 13% at the right commissure and 10% at the left commissure. Significant differences were detected at the wall area. S3 prostheses had significantly more thrombus-like formations than the XT prostheses. Additionally, in the S3 prostheses, the thrombus-like formation resembled a film whereas in the XT prostheses, the thrombus-like formation was like the crumbs of a cake. We noted exactly the same pattern in explanted prostheses from patients. CONCLUSIONS: The Sapien prostheses tend to form thromboses due to their flow properties. More than half of the thrombus-like formations were seen in the sinus. The S3 prostheses had significantly more thrombus-like formations than the XT prostheses in the wall area. There are different patterns of thrombus-like formations in XT and S3 prostheses used for transcatheter aortic valve implantation both in vivo and in vitro.