What is the recommended management for a patient with a bioprosthetic tricuspid valve?

Management of Patients with Bioprosthetic Tricuspid Valve

Patients with bioprosthetic tricuspid valves require regular echocardiographic monitoring and anticoagulation with warfarin for 3-6 months after implantation, followed by lifelong low-dose aspirin therapy. 1, 2

Monitoring and Surveillance

• An initial transthoracic echocardiography (TTE) study is recommended after prosthetic valve implantation to establish baseline valve hemodynamics 1
• Repeat TTE is recommended if there is a change in clinical symptoms or signs suggesting valve dysfunction 1
• Transesophageal echocardiography (TEE) is recommended when clinical symptoms or signs suggest prosthetic valve dysfunction 1
• Annual TTE is reasonable in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status 1

Anticoagulation Management

Initial Period After Implantation

• After tricuspid valve replacement with a bioprosthetic valve, warfarin therapy to achieve an INR of 2.0-3.0 is reasonable for 3-6 months after implantation 1, 2
• This initial anticoagulation helps prevent early thromboembolism while the prosthetic valve is being endothelialized 1

Long-term Anticoagulation

• After the initial anticoagulation period, lifelong low-dose aspirin therapy is reasonable 1
• For patients with decreased right ventricular function or other thromboembolic risk factors, long-term anticoagulation with warfarin to achieve an INR of 2.0-3.0 may be reasonable 1

Management of Complications

Prosthetic Valve Dysfunction

• Repeat TTE is recommended if there is a change in clinical symptoms or signs suggesting valve dysfunction 1
• TEE is recommended when clinical symptoms or signs suggest prosthetic valve dysfunction 1
• For patients with symptoms due to severe primary tricuspid regurgitation (TR) that are unresponsive to medical therapy, tricuspid valve surgery can be beneficial 1

Bioprosthetic Valve Failure

• Transcatheter valve-in-valve implantation is now an option for treating degenerated bioprostheses in patients with increased surgical risk 1, 3
• Experience with transcatheter tricuspid valve-in-valve procedures is growing, with studies showing it to be a safe and effective therapy for degenerative tricuspid bioprosthesis in high-risk patients 3, 4
• The procedure has demonstrated technical feasibility and safety in carefully selected patients 5, 6

Paravalvular Leak and Hemolysis

• Blood tests for hemolysis should be part of routine follow-up after valve replacement 1
• Lactate dehydrogenase levels, although non-specific, relate to the severity of hemolysis 1
• If a paravalvular leak is causing hemolysis requiring repeated blood transfusions or leading to severe symptoms, reoperation is recommended 1

Special Considerations

• The choice of valve intervention (repair or replacement) and type of prosthetic heart valve should be a shared decision-making process that accounts for the patient's values and preferences 1
• A bioprosthetic valve is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired 1
• Long-term outcomes for both bioprosthetic and mechanical tricuspid valves are similar, but bioprosthetic valves have a higher chance of requiring reoperation while mechanical valves have a higher risk of valve thrombosis 7

Common Pitfalls and Caveats

• Inadequate anticoagulation in the early post-implantation period may increase the risk of thromboembolism 1
• Failure to monitor for signs of valve dysfunction may lead to delayed diagnosis of complications 1
• The risk of bioprosthetic valve deterioration increases significantly after 10 years, necessitating more vigilant monitoring 1
• Patients with bioprosthetic tricuspid valves who develop symptoms should be evaluated promptly with appropriate imaging to assess for valve dysfunction 1