Intentional leaflet modification during valve-in-valve TAVR is associated with a significantly reduced incidence of hypoattenuated leaflet thickening (HALT), suggesting a protective association with subclinical leaflet thrombosis beyond coronary obstruction prevention.
Key Findings
Results
Patients undergoing leaflet modification had a significantly lower incidence of HALT compared to those without leaflet modification.
HALT occurred in 19.7% of patients with leaflet modification vs 40% without leaflet modification (P < 0.01)
The study included 141 total patients: 61 received leaflet modification and 80 underwent standard ViV TAVR without leaflet modification
This finding persisted after analysis was restricted to self-expanding transcatheter heart valves
No cases of HALT were observed in patients undergoing dual-leaflet modification
Results
Leaflet modification was associated with significantly lower postprocedural mean transvalvular gradients.
Mean transvalvular gradient was 13 ± 6 mm Hg in the leaflet modification group vs 18 ± 9 mm Hg in the standard ViV TAVR group (P < 0.001)
This suggests a hemodynamic benefit of leaflet modification beyond coronary obstruction prevention
The lower gradients may reflect improved flow dynamics through the modified valve
Results
Leaflet modification was more commonly performed in female patients and those with smaller prosthetic valves.
Leaflet modification was more frequent in female patients: 62.3% vs 45% in the standard ViV TAVR group (P = 0.04)
Leaflet modification was more frequent in patients with small (≤21 mm) prosthetic valves: 50% vs 22.5% (P < 0.001)
These differences in baseline characteristics highlight selection factors influencing the decision to perform leaflet modification
Results
HALT involving multiple leaflets was numerically less common with leaflet modification, and thrombosis predominantly affected nonlacerated cusps.
Multi-leaflet HALT occurred in 33.3% of HALT cases with leaflet modification vs 65.6% without leaflet modification (P = 0.054)
Thrombosis predominantly affected nonlacerated cusps: 66.6% vs 33.3%
This distribution suggests that laceration of a leaflet may physically prevent thrombus formation on that specific cusp
Results
Reduced leaflet motion was identified in approximately one-third of patients with HALT, with no significant difference between the leaflet modification and standard ViV TAVR groups.
Reduced leaflet motion was found in one-third of patients with HALT overall
There was no statistically significant difference in reduced leaflet motion between groups
Reduced leaflet motion is a functional consequence of HALT detectable on multidetector computed tomography
Methods
Predictors of HALT were assessed using multivariable logistic regression with clinically relevant covariates in a retrospective study design.
This was a retrospective analysis of 141 patients undergoing ViV TAVR with postprocedural multidetector computed tomography
A sensitivity analysis stratified outcomes by transcatheter heart valve type
Baseline characteristics, post-TAVR computed tomographic findings, and procedural outcomes were compared between groups
The BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) technique was the primary leaflet modification method referenced
What This Means
This research examines a procedure called valve-in-valve transcatheter aortic valve replacement (ViV TAVR), which is used when a previously implanted biological heart valve wears out and needs to be replaced by placing a new valve inside the old one. One known complication of this procedure is the formation of tiny blood clots on the new valve's leaflets (the flaps that open and close), which can be detected by CT scan as a finding called hypoattenuated leaflet thickening (HALT). The study investigated whether intentionally cutting or modifying the old valve's leaflets before placing the new valve — a technique originally developed to prevent blockage of coronary arteries — might also reduce these clots.
The study found that among 141 patients who underwent ViV TAVR, those who had leaflet modification had significantly fewer cases of HALT (about 20%) compared to those who did not have the modification (about 40%). Additionally, when both leaflets were modified, no cases of HALT were found at all. The clots that did form tended to appear on the leaflets that had not been cut, further supporting the idea that the modification itself may prevent clot formation on individual cusps. Patients who had leaflet modification also had lower pressure gradients across their new valves, suggesting the blood flowed more freely through the modified valve.
This research suggests that leaflet modification during ViV TAVR may offer benefits beyond its original purpose of preventing coronary artery blockage — specifically, it may help protect against subclinical leaflet thrombosis. Because the study was retrospective and patients were not randomly assigned to groups, the findings need to be confirmed in prospective studies. Nevertheless, these results could influence how clinicians approach ViV TAVR procedures, particularly in patients at higher risk for valve-related blood clots.
Rotta Detto Loria J, Dumpies O, Abdelhafez A, Richter I, Majunke N, Feistritzer H, et al.. (2026). Impact of Leaflet Modification on the Occurrence of Hypoattenuated Leaflet Thickening After Valve-in-Valve Transcatheter Aortic Valve Replacement.. JACC. Cardiovascular interventions. https://doi.org/10.1016/j.jcin.2026.01.313