Hypo-attenuated leaflet thickening after Perceval sutureless bioprosthesis implantation

Modern multi-slice computed tomography (CT) has increased the detection of hypo-attenuated leaflet thickening (HALT). Furthermore, HALT's impact on transcatheter or surgical biological aortic valve (AV) prostheses has attracted attention. However, few reports on HALT in sutureless bioprostheses exist. Herein, we report a case of early structural valve deterioration due to HALT after AV replacement (AVR) with a Perceval bioprosthesis, which improved after anticoagulation therapy. A 79-year-old man admitted to our hospital with paroxysmal atrial fibrillation (PAF) during hemodialysis was also diagnosed with AV stenosis and, coronary artery disease, and PAF. He underwent AVR, coronary artery bypass grafting, and left atrial appendage resection. Although the postoperative course was uneventful with dual antiplatelet therapy, postoperative enhanced CT revealed HALT with reduced leaflet motion, and echocardiography showed an increased transvalvular pressure gradient. After using warfarin with target prothrombin time-international normalized ratio of 2-2.5 and/or heparin with target activated partial thromboplastin time of 45-60 s, the HALT disappeared with an improved transvalvular pressure gradient without any thromboembolic events.