Key result
Early post-TAVR leaflet thickening progresses to severe multileaflet HALT with a ~26-mmHg gradient increase.
Why the study?
The significance of an isolated leaflet abnormality detected on 4D-CT during the first postoperative week after TAVR remains uncertain.
Case Report (n=1)
No
This case demonstrates the longitudinal evolution from an isolated day-7 post-TAVR focal leaflet thickening with preserved motion to hemodynamically significant multileaflet HALT at 7.5 months in a high-risk hemodialysis patient, highlighting the utility of integrating serial cardiac CT and echocardiography.
Answers are grounded in this paper and cite their sources.
Early post-TAVR focal thickening may progress to obstructive HALT in hemodialysis patients; leaves open whether serial 4D-CT surveillance improves outcomes.
Background Electrocardiographically gated multiphase cardiac computed tomography (4D-CT) is the reference imaging technique for detecting hypoattenuated leaflet thickening (HALT) and assessing associated leaflet-motion abnormalities after transcatheter aortic valve replacement (TAVR). The significance of an isolated abnormality detected during the first postoperative week remains uncertain. Case description A 51-year-old woman receiving maintenance hemodialysis for 13 years underwent transfemoral TAVR with a 23-mm Edwards SAPIEN 3 valve. A visible prosthetic waist was treated by balloon post-dilatation, reducing the invasive transvalvular gradient from 60 to 1 mmHg. Routine postoperative day-7 ECG-gated 4D-CT, reconstructed in 10 phases across the cardiac cycle, showed focal noncoronary cusp thickening measuring 2.5 mm on short-axis and 2.4 mm on long-axis images, with preserved leaflet motion. The immediate post-TAVR mean gradient was 4 mmHg; the nearest early follow-up examination on postoperative day 6 showed a mean gradient of 11 mmHg and a Doppler velocity index of 0.50. Serial echocardiography subsequently showed progressive hemodynamic deterioration. At approximately 7.5 months, limited-phase ECG-gated CT comprising paired systolic and diastolic reconstructions demonstrated multileaflet HALT with predominant right coronary cusp involvement. The abnormal tissue measured approximately 85 HU, extended 14.7 mm longitudinally, reached a maximal thickness of 3.1 mm, and was associated with an estimated 75% reduction in systolic leaflet excursion. The contemporaneous mean gradient was 25 mmHg and increased to 30 mmHg approximately 3 weeks later. Conclusion This case documents a temporal sequence from an early focal leaflet abnormality with preserved motion to multileaflet HALT, marked motion restriction, and prosthetic valve hemodynamic deterioration. The sequence supports integrated longitudinal assessment but does not establish that the early focal lesion predicted or caused the subsequent HALT.
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Liu et al. (2026) conducted a case report in Severe aortic stenosis with moderate-to-severe aortic regurgitation and hypoattenuated leaflet thickening (HALT) after TAVR (n=1). Transfemoral TAVR with a 23-mm Edwards SAPIEN 3 valve, balloon post-dilatation, and reduced-intensity apixaban was evaluated on Evolution of prosthetic leaflet abnormalities on cardiac CT and transvalvular hemodynamic gradients on echocardiography. Serial 4D-CT after TAVR showed day-7 focal 2.5-mm cusp thickening evolve by 7.5 months into multileaflet HALT (3.1 mm, 75% excursion reduction) with mean gradient rising from 4 to 30 mmHg.
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