COVID-19-associated acute transcatheter aortic valve thrombosis

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Leaflet thrombosis occurs relatively frequently after transcatheter aortic valve implantation (TAVI), with the majority of patients following a sub-clinical course.1 Clinical prosthesis thrombosis is a rare but potentially devastating complication.2 A percutaneous transcatheter aortic valve SAPIEN 3 Ultra 26 mm (Edwards Lifesciences, Irvine, CA, USA) was implanted in a 76-year-old male. He was treated by therapeutic aspirin. He presented in our centre 3 days after TAVI, a transient conductance disorder, and sub-clinical congestive heart failure due to acute leaflet thrombosis in the setting of COVID-19 infection. Initial echocardiographic evaluation revealed increased cusp thickness and mean transvalvular gradient at 57 mmHg (Vmax 4.7 m/s) (Figure 1A and B). Computed tomography scan demonstrated hypo-attenuated leaflet thickening (HALT) and reduced leaflet motion (RLM) confirming valve thrombosis (Figure 1C and D). Patient was initially treated with low-molecular-weight heparin on top of mono-antiplatelet therapy with a satisfactory clinical and echocardiographic response. At discharge, the patient treatment was switched to sole non-vitamin K antagonist oral anti-coagulant (NOAC): apixaban 5 mg × 2. Two months later, follow-up showed improvement of mean transvalvular gradient at 12 mmHg (Vmax 2.4 m/s) and resolution of HALT and RLM (Figure 1E–G). (A) Doppler trans-thoracic echocardiography showing a trans-aortic valve mean pressure gradient of 57 mmHg (Vmax 4.7 m/s) on admission suggestive of acute transcatheter aortic valve implantation thrombosis. (B) Trans-oesophageal echocardiography demonstrating leaflet thickening. (C) Computed tomography scan short-axis view with valve open showing a hypo-attenuated leaflet thickening suggestive of thrombus involving the base of leaflets. (D) Computed tomography scan short-axis view with valve closed showing a hypo-attenuated leaflet thickening suggestive of thrombus involving the base of leaflets. (E) Doppler trans-thoracic echocardiography showing an improvement of trans-aortic valve mean pressure gradient of 12 mmHg (Vmax 2.4 m/s) after 2 months of anti-coagulant therapy by non-vitamin K antagonist oral anti-coagulant: apixaban 5 mg × 2. (F) Computed tomography scan short-axis view with valve open showing a resolution of hypo-attenuated leaflet thickening after 2 months of anti-coagulant therapy by non-vitamin K antagonist oral anti-coagulant: apixaban 5 mg × 2. (G) Computed tomography scan short-axis view with valve closed showing a resolution of hypo-attenuated leaflet thickening after 2 months of anti-coagulant therapy by non-vitamin K antagonist oral anti-coagulant: apixaban 5 mg × 2. Data about TAVI thrombosis in the setting of COVID-19 infection are scare. To our knowledge, this is the first case report of COVID-19-associated early valve thrombosis resolving on NOAC in a patient with TAVI. The precise mechanism for presumed COVID-19-related leaflet thrombosis remains unknown. It seems to be an endothelial damage secondary to direct viral injury. An increased inflammatory cytokine production and upregulation of coagulation pathways were promoted likely by COVID-19 infection.3 This case reminds us that patients with prosthetic heart valves may be at particular risk of thrombotic complications from COVID-19. The authors have no thanks to give. Consent: The patient has signed a written consent form in compliance with COPE guidelines. Funding: None declared. It is not ethically feasible for authors to make all data and software code on which the conclusions of the paper are available to readers.

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