JACC: CASE REPORTS VOL. 4, NO. 11, 2022 ª 2022 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/). MINI-FOCUS ISSUE: PROCEDURAL COMPLICATIONS CASE REPORT: CLINICAL CASE SERIES Aortic Sinus Contrast Retention During TAVR A Warning Sign Preceding a Potential Thrombotic Complication Lluis Asmarats, MD, PHD, Chi-Hion Li, MD, Xavier Millán, MD, PHD, Irene Menduiña, MD, Estefanía Fernández-Peregrina, MD, Lola Gutiérrez-Alonso, MD, Mario Torres, MD, Antonio Serra, MD, PHD, Dabit Arzamendi, MD, PHD ABSTRACT Sinus contrast material retention after transcatheter aortic valve replacement (TAVR) is a rare phenomenon that may reflect an increased risk for thrombotic complications. We present 3 cases of persistent contrast agent retention in the sinus of Valsalva during the TAVR procedure that portend the occurrence of embolic stroke or bioprosthetic valve thrombosis. (Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2022;4:666–670) © 2022 The Authors. Pub- lished by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). INTRODUCTION TAVR may occur as a combination of changes in the coagulation cascade, along with modification of flow Despite the continued expansion of transcatheter dynamics (blood stasis resulting from stagnant flow in aortic valve replacement (TAVR) indications, throm- the sinuses of Valsalva [SoVs]). Here we present a botic events (stroke and valve thrombosis) following series of 3 patients presenting with early thrombotic TAVR remain a relevant concern. The incidence of complications after TAVR, all preceded by dense, cerebrovascular events post-TAVR ranges from 1% to persistent contrast material retention within the SoVs 11%, with an estimated incidence of subclinical leaflet during valve implantation. thrombosis of 10% to 15%.1,2 Thrombotic events post- PATIENT 1 LEARNING OBJECTIVES An 86-year-old woman with previous breast cancer  To recognize the retention of contrast ma- treated with surgery and radiotherapy and severe terial in the sinus of Valsalva during TAVR. symptomatic aortic stenosis with a mean gradient of  To identify this characteristic imaging 38 mm Hg was referred for TAVR. Preprocedural finding as a warning for potential thrombotic computed tomography (CT) confirmed severe calcific complications. aortic stenosis (calcium score, 2,372 AU) extending  To provide close neurovascular surveillance toward the left ventricular outflow tract, with an aortic and consider early anticoagulation when annulus area of 402 mm 2, perimeter of 72 mm and observing this rare phenomenon. mean diameter of 23 mm, large SoVs (32 mm), and a From the Department of Cardiology, Santa Creu i Sant Pau Hospital, Autonomous University of Barcelona, Barcelona, Spain. The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center. Manuscript received February 23, 2022; accepted March 28, 2022. ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2022.03.031 JACC: CASE REPORTS, VOL. 4, NO. 11, 2022 Asmarats et al 667 JUNE 1, 2022:666–670 Aortic Sinus Contrast Retention During TAVR narrow sinotubular junction ([STJ] 22 mm; 13 mm/m 2) Brain CT showed no new onset ischemic le- ABBREVIATIONS (Figures 1A and 1B). Given the potential risk of annulus sions, and the patient was discharged home AND ACRONYMS rupture, transfemoral TAVR with a mechanically with aspirin therapy 9 days after the proced- AF = atrial fibrillation expandable valve (Lotus, Boston Scientific) was plan- ure. At 6-month follow-up, the patient had CT = computed tomography ned. Unfractionated heparin (70 U/kg) was used in all nearly full recovery of neurologic signs with SoV = sinus of Valsalva procedures. After valvuloplasty with a 20-mm balloon, normal TAVR function. a 23-mm valve was successfully implanted on the first STJ = sinotubular junction attempt. Before valve release, marked contrast mate- PATIENT 2 STS = Society of Thoracic Surgeons rial retention and slow washout were noticed in the TAVR = transcatheter aortic left coronary cusp (Figures 1C and 1D, Videos 1 to 3). A 73-year-old woman with severe aortic ste- valve replacement Transthoracic echocardiography showed a mean nosis was referred for aortic valve replace- gradient of 6 mm Hg and no residual aortic regurgita- ment. She had a history of severe chronic obstructive tion. Three hours after the procedure, the patient pulmonary disease, previous ischemic stroke, amy- experienced an acute right sensorimotor syndrome loid angiopathy-related cerebellar hemorrhage, per- (right-sided hemiparesis and sensory impairment). manent atrial fibrillation (AF) with percutaneous left F I G U R E 1 Patient 1 (A and B) Pre–transcatheter aortic valve replacement computed tomography scan showing severe valve calcification and a narrow sinotubular junction. (C and D) Fluoroscopic view showing the upper stent frame extending above the sinotubular junction with contrast agent retention (asterisks) in the left coronary sinus during and after valve implantation. 668 Asmarats et al JACC: CASE REPORTS, VOL. 4, NO. 11, 2022 Aortic Sinus Contrast Retention During TAVR JUNE 1, 2022:666–670 F I G U R E 2 Patient 2 (A and B) Baseline computed tomography showing moderate valve calcification and a calcified sinotubular junction. (C and D) Aortography showing a short valve-to-aortic-wall distance above the noncoronary sinus with persistent contrast agent stagnation (asterisks). atrial appendage occlusion, and end-stage renal dis- of the left middle cerebral artery (M2 segment), and ease. After heart team review (Society of Thoracic the patient underwent emergency thrombectomy Surgeons [STS] risk score, 8.7%) and given her severe with TICI (Thrombolysis In Cerebral Infarction) grade peripheral vascular disease, left transaxillary TAVR 2b partial recanalization. Unfortunately, the patient was indicated. Preprocedural CT showed moderate developed hemorrhagic transformation and died aortic valve calcification, with an aortic annulus 3 weeks after the procedure. perimeter of 69 mm and an area of 361 mm2 and a calcified STJ (Figures 2A and 2B). After predilatation PATIENT 3 with a 20-mm balloon, a 25-mm Portico (Abbott Vascular) valve was implanted with no need for An 84-year-old woman was admitted with an out-of- repositioning or recapture. Final angiography showed hospital cardiac arrest. She had a history of verte- mild residual aortic regurgitation, with dense brobasilar insufficiency and nonischemic dilated contrast agent stagnation at the noncoronary sinus cardiomyopathy with moderate left ventricular (Figures 2C and 2D, Videos 4 and 5). Four hours later, dysfunction. Transthoracic echocardiography showed the patient experienced right hemiparesis (4/5) and severe aortic regurgitation with worsening left ven- aphasia. Emergency head CT scan revealed occlusion tricular systolic function (27%). Cardiac CT showed no JACC: CASE REPORTS, VOL. 4, NO. 11, 2022 Asmarats et al 669 JUNE 1, 2022:666–670 Aortic Sinus Contrast Retention During TAVR F I G U R E 3 Patient 3 (A) Baseline computed tomography showing no valve calcification. (B and C) Contrast agent stagnation in the noncoronary sinus (asterisks) during and after valve implantation. (D) Hypoattenuation at the base of the commissure between the right and noncoronary cusps (arrowhead) with reduced leaflet motion. (E) Angles between each commissure and the right coronary artery (RCA) with no significant commissural misalignment. coronary artery disease and mild aortic valve calcifi- DISCUSSION cation (49 AU), with an aortic annulus perimeter of 72 mm and an area of 416 mm 2 (Figure 3A). After heart Sinus contrast material retention after TAVR is a rare team review, an implantable cardioverter- phenomenon potentially translating to an increased defibrillator was inserted, and TAVR was indicated thrombotic risk. The underlying etiologic factors may (STS risk score, 5.0%). The procedure was performed involve the Virchow triad: endothelial injury or focal through transfemoral access, and after 2 recaptures, a sinus dissection (after predilatation, during delivery 34-mm Evolut Pro (Medtronic) valve was successfully system advancement, recapturing or repositioning implanted with no residual aortic regurgitation. maneuvers, pigtail entrapment), blood stasis (flow Given the presence of dense contrast material stag- stagnation and reduced washout within the neosinus, nation in the noncoronary cusp in the aortogram a narrow or low STJ), and hypercoagulability (older (Figures 3B and 3C, Videos 6 and 7), the patient was adult patients with cardiovascular risk factors). discharged on low-dose direct oral anticoagulant In patients undergoing percutaneous left atrial therapy. At 1-month follow-up, a CT scan showed appendage occlusion, postangiography retention of subclinical leaflet thrombosis between the non- contrast material in the left atrial appendage has coronary and right coronary cusps (Figures 3D and 3E) been associated with an increased risk of device- that resolved with low-molecular-weight heparin related thrombosis and a higher risk of thromboem- treatment. bolic stroke.3 Of note, thrombosis is most likely to 670 Asmarats et al JACC: CASE REPORTS, VOL. 4, NO. 11, 2022 Aortic Sinus Contrast Retention During TAVR JUNE 1, 2022:666–670 occur in low-flow regions with long blood residence experiencing a stroke, only 1 had a history of stroke, time and poor washout.4 In particular, sinus and none of the thrombotic events were related to sequestration, which is most commonly seen in pa- carotid artery disease or new onset AF (chronic AF in 1 tients with a low and narrow STJ who are receiving patient with left atrial appendage occlusion and no taller-frame devices, may impair blood flow to the device-related thrombus or patency). Of note, both SoVs and coronary arteries and in turn may predis- strokes occurred immediately after the procedure, pose patients to thrombosis. STJ diameter and thus suggesting a procedure-related embolic origin, height are relevant to identify anatomical features at with most acute (#24 hours) cerebrovascular events risk of sinus sequestration in redo TAVR, as well as generally related to the procedure (thrombus, calcific in native valves. Both patients 1 and 2 had narrow embolization, endothelium denudation) rather than STJs (22 and 26 mm, respectively), the former with a to pre-existing comorbidities.1 low STJ (18 mm; 1 mm shorter than the 19-mm Low-dose aspirin has become the preferred prosthesis height of the mechanically expandable antithrombotic therapy (over dual antiplatelet ther- valve) and the latter with STJ calcification. Hence, a apy) post-TAVR in patients without an indication for short residual distance between the valve and the oral anticoagulant therapy. However, observation of STJ in patients with small anatomical features may persistent contrast agent retention immediately after create a cul de sac in the SoVs that contributes to TAVR may prompt close neurovascular monitoring thrombus formation, akin to the phenomenon and consideration for early anticoagulation and sur- observed in patients with incomplete sealing of the veillance imaging to enable early recognition and left atrial appendage. In other patients, sequestra- management of ischemic complications. However, tion may be functional rather than anatomical, as a given the limited number of patients and other po- combination of reduced sinus washout, stasis, and tential sources for cerebral emboli, these findings proneness to thrombosis, and thus more difficult to should be interpreted with caution and remain hy- predict by CT. Indeed, it has been speculated that pothesis generating. blood flow stagnation in large SoVs could also in- crease the risk of hypoattenuated leaflet thickening FUNDING SUPPORT AND AUTHOR DISCLOSURES 5 after TAVR. This was the case in patient 3, who, Drs Asmarats, Millan, and Arzamendi have received proctoring and despite large SoVs and STJ, had follow-up CT that speaker fees from Abbott. All other authors have reported that they showed isolated thrombosis of the noncoronary have no relationships relevant to the contents of this paper to cusp. There is also evidence that native-to- disclose. prosthetic commissural misalignment may reduce upper sinus flow by 40% which may increase the ADDRESS FOR CORRESPONDENCE: Dr Dabit Arza- likelihood of thrombus formation, although this hy- mendi, Interventional Cardiology Unit, Hospital de la pothesis could not be explored in our patients.6 Santa Creu i Sant Pau, Sant Antoni M. Claret, 167, Previous stroke and new onset AF infer a higher 08025 Barcelona, Spain. E-mail: darzamendi@ risk for stroke post-TAVR. In the 2 patients santpau.cat. REFERENCES 1. Armijo G, Nombela-Franco L, Tirado-Conte G. thromboembolic risk in patients with atrial fibrilla- 6. Salmonsmith JA, Ducci A, Burriesci G. Does Cerebrovascular events after transcatheter aortic tion. J Thromb Thrombolysis. 2022;53(1):191–201. transcatheter aortic valve alignment matter? Open valve implantation. Front Cardiovasc Med. 2018;5: Heart. 2019;6:e001132. 4. Vahidkhah K, Barakat M, Abbasi M, et al. 104. Valve thrombosis following transcatheter aortic 2. Cahill TJ, Khalique OK, George I, Kodali S. valve replacement: significance of blood stasis KEY WORDS stroke, thrombosis, Valve thrombosis after transcatheter and surgical on the leaflets. Eur J Cardiothorac Surg. 2017;51: transcatheter aortic valve replacement aortic valve replacement: incidence and out- 927–935. comes. J Thorac Cardiovasc Surg. 2022;163(4): 5. Yanagisawa R, Hayashida K, Yamada Y, et al. 1309–1315. Incidence, predictors, and mid-term outcomes of AP PE NDIX For supplemental 3. Lu X, Chen T, Liu G, et al. Relations between left possible leaflet thrombosis after TAVR. J Am Coll videos, please see the online version of atrial appendage contrast retention and Cardiol Img. 2017;10(1):1–11. this article.