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Gregor Pache, Philipp Blanke, Wolfgang Zeh, Nikolaus Jander, Cusp thrombosis after transcatheter aortic valve replacement detected by computed tomography and echocardiography, European Heart Journal, Volume 34, Issue 46, 7 December 2013, Page 3546, https://doi.org/10.1093/eurheartj/eht316
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An 86-year-old male underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis with an Edwards Sapien 29 mm XT valve and percutaneous coronary intervention simultaneously. Periprocedural transoesophageal echocardiography (TOE) showed good positioning and expansion of the prosthesis with only minor paravalvular insufficiency. Routine post-TAVR computed tomography angiography (CTA) performed 7 days after implantation revealed a crescent shaped, hypoattenuating structure adherent to the prosthesis cusp located in the former native left-coronary cusp position (Panels A–C). Rigidity of the cusp was displayed by 4D-cine CT imaging and confirmed by TOE (Panels D and E; Supplementary material online, Videos S1 and S2), suggestive of cusp thrombosis. Despite restricted cusp movement, the mean pressure gradient (9 mmHg) was normal. Post-interventional anticoagulation therapy had consisted of daily aspirin and clopidogrel, while heparin had been paused from Day 4 to 7 post-intervention due to perianal bleeding complications. After restoring coumadin therapy, the patient had received for 3 years due to a history of pulmonary embolism and which had been paused prior to TAVR, 10-week follow-up CTA (Panel F) and TOE showed complete disappearance of the initial finding, underlying the diagnosis of cusp thrombosis. As to our knowledge, this is the first report of a cusp thrombosis of a transcatheter aortic valve detected by computed tomography.