In patients with prosthetic valve stenosis within the first few years after the procedure, an attempt of anticoagulation should be performed before considering a second procedure or valve-in-valve implantation, according to authors of a research correspondence published on Dec. 5 in the Journal of the American College of Cardiology. The authors looked at three patients with symptomatic bioprosthetic dysfunction within one to two years after transfemoral implantation of a SAPIEN XT valve and identified a potentially reversible cause of transcatheter heart valve (THV) dysfunction through anticoagulation therapies.

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The first patient, an 83-year-old man, was referred for severe symptomatic aortic stenosis (AS) and a transfemoral transcatheter aortic valve implantation (TAVI) was performed. The patient was discharged on dual antiplatelet therapy, but upon complaints of dyspnea, the patient was then admitted and vitamin K antagonist was added to the regiment. At eight months, the patient remained on aspirin, clopidogrel and vitamin K antagonist, and was asymptomatic (mean gradient 11 mm Hg).

In the second patient, a TAVI was performed on an 81-year-old man with hypertension, renal insufficiency and severe AS. Fifteen months later, he presented with worsening exertional dyspnea and was given vitamin K antagonist in addition to aspirin, which resulted in rapid resolution of symptoms and gradient (19 mm Hg).
 
The third patient was an 83-year-old male with hypertension, dyslipidemia, previous stroke and severe symptomatic AS. The patient underwent a 26 mm Sapient XT transfemoral implantation. At two years he presented with shortness of breath and elevated aortic gradients without worsening of the paravalvular leak. Vitamin K antagonist was added to his regiment and resulted in gradient normalization (13 mm Hg) and marked symptomatic improvement.
 
The authors note that "although there have been reports of reversible dysfunction of surgical bioprostheses with anticoagulation, the optimal antithrombotic therapy after surgical or transcatheter bioprostheses implantation is still uncertain." Based on their experiences, they conclude that there is a need for "further investigation on the optimal antithrombotic strategy after TAVI." Meanwhile, follow-up echocardiography to evaluate prosthetic valve function is critical in evaluating  patients with clinical deterioration after transcatheter aortic valve replacement (TAVR).

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