What is the management for a patient with a bioprosthetic (biological prosthetic) valve who develops an ejection systolic murmur and heart failure?

From the Guidelines

A patient with a bioprosthetic valve who develops an ejection systolic murmur and heart failure should undergo immediate echocardiography to evaluate for prosthetic valve dysfunction, particularly structural valve deterioration, as recommended by the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1. This is likely prosthetic valve stenosis, which commonly occurs due to calcification or pannus formation in bioprosthetic valves after several years of implantation. Initial management includes:

• Diuretics (such as furosemide 40mg daily, titrated as needed) to relieve congestion
• Standard heart failure therapy including ACE inhibitors/ARBs and beta-blockers as tolerated Blood cultures should be obtained to rule out infective endocarditis. The definitive treatment is typically surgical valve replacement, though transcatheter valve-in-valve procedures may be appropriate for high-risk surgical candidates, as stated in the 2014 AHA/ACC guideline 1. The timing of intervention depends on symptom severity, hemodynamic significance of the stenosis, and left ventricular function. Prompt cardiology and cardiac surgery consultation is essential, as progressive valve dysfunction can lead to irreversible myocardial damage and worsening heart failure, highlighting the importance of regular follow-up with serial echocardiography to detect deterioration before symptomatic heart failure develops, in line with the recommendations for annual TTE in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status 1. Additionally, patients with LV systolic dysfunction after valve surgery should receive standard medical therapy for systolic heart failure, which should be continued even if there is improvement of LV dysfunction, as recommended by the 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease 1. TTE is also indicated in patients with suspected prosthetic valve thrombosis to assess hemodynamic severity and follow resolution of valve dysfunction, as stated in the 2014 AHA/ACC guideline 1.

From the Research

Diagnosis and Evaluation

• The patient with a bioprosthetic valve presenting with an ejection systolic murmur and heart failure requires thorough evaluation to determine the cause of the symptoms 2, 3.
• Echocardiography, including transthoracic and transesophageal echocardiography, is essential for assessing valve function, leaflet motion, and thrombus size 4.
• The diagnosis of bioprosthetic valve dysfunction (BVD) or bioprosthetic valve failure (BVF) should be based on standardized definitions, including confirmation of permanent structural changes to the leaflets and evidence of deterioration in valve hemodynamic function at echocardiography follow-up 2.

Possible Causes

• Bioprosthetic valve thrombosis (BPVT) is a potential cause of early prosthetic valve dysfunction (PVD) and can lead to rapid symptomatic deterioration 3.
• Other possible causes of early bioprosthetic valve failure include excessive pannus formation, calcification, and primary tears 5.
• In rare cases, intraoperative bioprosthetic valve dysfunction can occur immediately after implantation, causing severe mitral regurgitation 6.

Management

• Management of non-obstructive thrombus is primarily optimization of anti-coagulation, while treatment of obstructive thrombus requires a decision between slow, low-dose fibrinolysis or valve surgery 4.
• The choice of treatment depends on various factors, including thrombus size, New York Heart Association Class, presence of concomitant coronary artery disease or other valve dysfunction, surgical risk, and contraindication to fibrinolysis 4.