What is the management approach for suspected prosthetic valve dysfunction?

Management of Suspected Prosthetic Valve Dysfunction

When prosthetic valve dysfunction is suspected based on new symptoms (dyspnea, heart failure signs, new murmur, embolic events) or physical examination findings (muffled clicks, new murmurs), immediately obtain transthoracic echocardiography (TTE) followed by transesophageal echocardiography (TEE) for complete evaluation. 1

Initial Diagnostic Approach

Clinical Recognition

• Bioprosthetic valve dysfunction typically presents with insidious onset of exertional dyspnea, a louder systolic murmur (mitral regurgitation or aortic stenosis), or a new diastolic murmur (aortic regurgitation or mitral stenosis) 1
• Mechanical valve dysfunction presents more acutely with heart failure symptoms, systemic thromboembolism, hemolysis, or new murmurs on auscultation 1
• Suspect valve thrombosis specifically if there is recent inadequate anticoagulation (subtherapeutic INR) or increased coagulability states (dehydration, infection) 1, 2

Mandatory Imaging Sequence

Both TTE and TEE are required for complete evaluation—neither alone is sufficient. 1

1. Start with TTE (Class I recommendation): 1

   • Allows proper Doppler beam alignment for measuring transvalvular velocity, gradient, and valve area
   • Quantifies LV volumes, LVEF, pulmonary pressures, and right heart function
   • Critical limitation: Cannot adequately visualize the left atrial side of mitral prostheses due to acoustic shadowing 1

2. Follow with TEE (Class I recommendation): 1

   • Mandatory when clinical symptoms or signs suggest prosthetic valve dysfunction
   • Superior for detecting prosthetic mitral regurgitation, thrombus, pannus, and vegetations on the left atrial side 1
   • Critical for aortic prostheses: The posterior aspect is shadowed on TTE and the anterior aspect is shadowed on TEE, requiring both modalities 1

3. Add fluoroscopy or CT imaging for mechanical valves: 1

   • Particularly helpful when mechanical valve stenosis is suspected
   • Assesses valve occluder motion and detects reduced motion from pannus or thrombus 1, 3
   • Opening and closing angles can be measured fluoroscopically to determine proper valve function 3

Specific Management by Etiology

Prosthetic Valve Thrombosis

For obstructive thrombosis in critically ill patients (NYHA Class III-IV), urgent or emergency valve replacement is the treatment of choice. 1

Multimodality Imaging (Class I)

• Urgent evaluation with TTE, TEE, fluoroscopy, and/or CT is indicated to assess valvular function, leaflet motion, and thrombus extent 1
• Different modalities are necessary because valve function, leaflet motion, and thrombus extent must all be evaluated 1

Treatment Algorithm Based on Clinical Severity

For NYHA Class III-IV symptoms or large/mobile thrombus (>0.8 cm²):

• Emergency surgery is recommended 1
• Surgery avoids the risks of systemic embolism and recurrent thrombosis associated with fibrinolysis 1

For NYHA Class I-II symptoms with recent onset (<14 days) and small thrombus (<0.8 cm²):

• Fibrinolytic therapy is reasonable using recombinant tissue plasminogen activator (10 mg bolus + 90 mg over 90 minutes with UFH) or streptokinase (1,500,000 U over 60 minutes without UFH) 1
• Consider fibrinolysis when surgery is unavailable, very high risk, or for right-sided prosthesis thrombosis 1

For non-obstructive thrombosis with large thrombus (>10 mm) complicated by embolism:

• Surgery should be considered 1

For bioprosthetic valve thrombosis:

• Anticoagulation using VKA and/or UFH is recommended before considering reintervention 1

Structural Valve Degeneration

For severe symptomatic prosthetic valve stenosis or severe regurgitation, reoperation is recommended. 1

• Bioprosthetic regurgitation: Surgery is reasonable for operable patients with severe symptomatic or asymptomatic bioprosthetic regurgitation 1
• Mechanical valve regurgitation: Surgery is recommended for operable patients with intractable hemolysis or heart failure due to severe prosthetic or paravalvular regurgitation 1
• Transcatheter valve-in-valve: Should be considered by the Heart Team for aortic position depending on reoperation risk and prosthesis type/size 1

Paravalvular Leak

• Reoperation is recommended if paravalvular leak is related to endocarditis or causes hemolysis requiring repeated blood transfusions or leading to severe symptoms 1
• Percutaneous closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high-risk patients (Heart Team decision) 1

Surveillance Strategy

Bioprosthetic Valves

• Annual TTE is reasonable after the first 10 years (Class IIa), even without clinical status changes 1
• Bioprosthetic valve dysfunction incidence is low within 10 years but increases markedly thereafter 1
• Earlier evaluation is prudent for patients with renal impairment, diabetes mellitus, abnormal calcium metabolism, systemic inflammatory disease, or age <60 years 1

Mechanical Valves

• Routine annual echocardiography is not needed if the postoperative baseline study is normal and there are no signs or symptoms of valve dysfunction 1
• However, many patients require TTE for other indications (LV dysfunction, pulmonary hypertension, aortic disease, concurrent valve disease) 1

Critical Pitfalls to Avoid

• Do not rely on TTE alone for mitral prostheses: Low sensitivity for detecting prosthetic mitral regurgitation and thrombus due to acoustic shadowing 1
• Do not delay TEE when dysfunction is suspected: Clinical deterioration can be rapid, particularly with mechanical valve thrombosis 1, 2
• Compare with baseline postoperative echocardiogram: This is particularly helpful for detecting prosthetic valve dysfunction 1
• Distinguish thrombus from pannus: Thrombus is more likely with inadequate anticoagulation history and more acute symptom onset; pannus develops more gradually 1, 4, 5
• Do not miss small vegetations (<5 mm): TEE may miss these or those that have already embolized; repeat imaging in 3-5 days if clinical suspicion persists 6