Prosthetic Valve Thrombosis Management (ACC/AHA 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Prosthetic Valve Thrombosis

   Mechanical or bioprosthetic valve with suspected thrombus

   1. ●

      Action

      Clinical Presentation

      Recognize PVT signs

      • SYMPTOMS:
      • • New dyspnea / heart failure
      • • Embolic event (stroke, limb ischemia)
      • • Syncope
      • • New murmur (change in prosthetic sounds)
      • RISK FACTORS:
      • • Subtherapeutic anticoagulation (most common)
      • • Older-generation valves
      • • Mitral position (higher risk)
      1. ●

         Action

         Diagnostic Workup

         TEE is gold standard

         • TTE: initial screening
         • • Elevated gradients (compare to baseline)
         • • Decreased leaflet motion
         • TEE: REQUIRED for diagnosis (Class I)
         • • Direct visualization of thrombus
         • • Thrombus size measurement
         • • Differentiate thrombus vs pannus
         • Fluoroscopy: assess leaflet motion
         1. ◆

            Decision

            Obstructive or Non-Obstructive?

            Key determinant of urgency

            • OBSTRUCTIVE:
            • • High gradients
            • • Reduced effective orifice area
            • • Hemodynamic compromise
            • NON-OBSTRUCTIVE:
            • • Normal gradients
            • • Small thrombus <10mm
            • • Found incidentally or on surveillance
            1. ●

               Action

               Obstructive PVT

               Requires urgent intervention

               • TWO OPTIONS:
               • 1. SURGERY (Class I if available):
               • • Valve replacement/thrombectomy
               • • Preferred for large thrombus
               • • Lower embolic risk
               • 2. THROMBOLYSIS:
               • • When surgery high-risk/unavailable
               • • Embolic risk 10-15%
               • • See contraindications
               1. ●

                  Action

                  Surgical Intervention

                  Valve surgery for PVT

                  • OPTIONS:
                  • • Thrombectomy (if valve salvageable)
                  • • Valve re-replacement (most common)
                  • INDICATIONS (Class I):
                  • • Large thrombus (>10mm)
                  • • Mobile thrombus
                  • • Left-sided valve
                  • • Contraindication to thrombolysis
                  • Operative mortality 10-15%
                  • (higher if emergent)
                  1. ●

                     Action

                     Follow-Up & Prevention

                     Long-term management

                     • SURVEILLANCE:
                     • • Serial TEE until thrombus resolved
                     • • Regular INR monitoring
                     • • Annual TTE for gradients
                     • PREVENTION:
                     • • Strict anticoagulation adherence
                     • • INR self-testing if available
                     • • Patient education critical
                     1. ✓

                        Outcome

                        Thrombus Resolved / Valve Functional

                        Continue lifelong anticoagulation monitoring

               2. ●

                  Action

                  Thrombolysis

                  When surgery not feasible

                  • REGIMEN (Class IIa):
                  • • tPA 10mg bolus + 90mg over 90min
                  • • OR alteplase 25mg over 6h, repeat PRN
                  • • Monitor with serial TEE
                  • CONTRAINDICATIONS:
                  • • Recent stroke (<2 weeks)
                  • • Active bleeding
                  • • Recent major surgery
                  • • Large mobile thrombus
                  • Embolic risk: 10-15%
            2. ●

               Action

               Non-Obstructive PVT

               Anticoagulation optimization first

               • SMALL THROMBUS (<10mm):
               • • Optimize anticoagulation (IV UFH)
               • • Target higher INR (3.0-4.0)
               • • Low-dose aspirin
               • • Repeat TEE in 1-4 weeks
               • LARGER THROMBUS or symptomatic:
               • • Consider low-dose thrombolysis
               • • Or surgery
               1. ●

                  Action

                  Anticoagulation Optimization

                  For non-obstructive or post-treatment

                  • IV UFH bridge → warfarin
                  • Target INR 3.0-4.0 (higher)
                  • Low-dose aspirin 81mg
                  • INVESTIGATE CAUSE:
                  • • Non-compliance
                  • • Drug interactions
                  • • Dietary changes (vitamin K)
                  • ⚠️ DOACs CONTRAINDICATED
                  • in mechanical valves (RE-ALIGN)