The heterogeneity of response to direct oral anticoagulants in patients with hypoattenuating leaflet thickening

Hypoattenuating leaflet thickening (HALT) after transcatheter aortic valve implantation (TAVI) is common. Conflicting data exist on the association between HALT and haemodynamic valve deterioration (HVD)12. Treatment with oral anticoagulation in patients with suspected HALT-related transcatheter heart valve (THV) dysfunction may be recommended. However, there is no consensus on the choice or duration of anticoagulation. While small registry data have suggested that direct oral anticoagulants (DOACs) might be equally effective as warfarin for the treatment of HALT3, others have shown that DOACs were linked to a higher ischaemic event rate than warfarin in patients with an indication for anticoagulation post-TAVI4. Here, we highlight two cases of HALT associated with HVD and the heterogeneity of response to treatment with DOACs.

An 80-year-old female underwent transfemoral TAVI with a 26 mm SAPIEN 3 Ultra (S3U) valve (Edwards Lifesciences) for severe bicuspid aortic stenosis. The immediate post-TAVI transthoracic echocardiography (TTE) showed a mean gradient (MG) of 7 mmHg. On routine 30-day TTE, an increase in the MG was noted (MG: 22 mmHg). Computed tomography (CT) revealed severe (grade 4/4) and mild...