Suspected prosthetic valve thrombosis (adult)
Mechanical or bioprosthetic valve (surgical or TAVI) with new symptoms, an embolic event or a rise in gradients
All Pathways
Cardiothoracic SurgeryEmergency
Prosthetic Valve Thrombosis Management (ACC/AHA 2020, ESC/EACTS 2025)
Prosthetic Valve Thrombosis Management (ACC/AHA 2020, ESC/EACTS 2025): Suspected prosthetic valve thrombosis (adult) → Recognise and stabilise → Urgent ...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Recognise and stabilise
Check INR now. Shock or pulmonary oedema: call cardiology and cardiac surgery at once. Stroke symptoms: urgent CT brain and stroke team. Pregnant: involve obstetrics now.
- New dyspnoea, heart failure or pulmonary oedema
- Embolic event: stroke, TIA or limb ischaemia
- Muffled mechanical valve clicks or a new murmur
- Usual cause: subtherapeutic INR (missed doses, interactions, diet, illness)
- Higher risk: mitral or tricuspid position, first 3 months after implant
03Action Urgent imaging: TTE, then TEE and/or cardiac CT
TEE and/or CT confirms the thrombus and separates it from pannus. Fever or raised inflammatory markers: blood cultures before any lysis (endocarditis).
- TTE: gradients against baseline, leaflet motion, LV function, PA pressure
- Obstruction: mean gradient up >50% from baseline (aortic: up >10 mmHg)
- TEE (best for mitral) and/or 4D CT: thrombus present, size and mobility
- Fluoroscopy: mechanical leaflet motion (best for aortic)
- Pannus does not respond to anticoagulation or lysis
- A vegetation can look like thrombus: consider endocarditis, especially after an embolic event
04Decision Mechanical valve?
Yes: mechanical valve steps. No: bioprosthetic (surgical or TAVI) steps.
- If Yes
05Action Mechanical valve: restore anticoagulation (CT brain first if stroke)
Start IV unfractionated heparin (UFH) if the INR is below target. Stroke symptoms: CT brain before heparin; haemorrhage or large infarct: neurology and Heart Team decide timing. Continue while the team decides.
- UFH can be stopped quickly before surgery or lysis
- Active major bleeding: senior decision before heparin
- Do not use a DOAC for a mechanical valve
06Decision Obstructive thrombosis with heart failure or other symptoms of obstruction?
Yes: urgent Heart Team treatment. No: non-obstructive or no significant symptoms.
- If Yes
07Action Symptomatic obstructive thrombosis: urgent Heart Team decision
Two first-line options: emergency surgery or slow-infusion low-dose alteplase. Choose with cardiology, cardiac surgery and the patient.
- Favours surgery: shock or NYHA IV, large clot (>0.8 cm2), LA thrombus, recurrent thrombosis
- Favours surgery: possible pannus, lysis contraindicated, recent embolism, CAD or other valve disease needing surgery
- Favours lysis: high surgical risk or no surgeon, NYHA I-III, small clot, first episode
- Favours lysis: right-sided (tricuspid or pulmonary) mechanical valve
- Keep IV UFH running until the decision
08Decision Heart Team chooses low-dose lysis?
Yes: contraindication check, then alteplase. No: emergency surgery.
- If Yes
09Warning Before lysis: contraindications, stroke, endocarditis, pregnancy
If a contraindication applies, endocarditis or pannus is possible: choose emergency surgery.
- Contraindicated: prior intracranial haemorrhage, ischaemic stroke <6 months, CNS tumour or AVM, major surgery, trauma or head injury <1 month, GI bleed <1 month, bleeding disorder, aortic dissection, possible endocarditis. Relative: BP >180/110 mmHg despite treatment, prolonged or traumatic CPR
- Stroke or embolism at presentation: favours surgery; decide with neurology and the Heart Team
- Pregnant: cardiology, cardiac surgery and obstetric team decide; low-dose slow alteplase is an option in selected stable women
10Action Lysis chosen: slow-infusion low-dose alteplase (adult)
Adult fixed dose. No bolus. Give in a monitored bed with TTE/TEE follow-up.
- Alteplase 25 mg IV over 6 hours, no bolus
- Stop IV UFH before the infusion; restart it after the infusion
- Repeat TTE/TEE after each infusion; another 25 mg infusion only on Heart Team advice (published protocols: at most 8 infusions, 200 mg total)
- Stop the infusion for new neurological signs or major bleeding
- Ultraslow option used in trials: 25 mg over 25 hours
11Decision Valve function restored after lysis?
Yes: optimise anticoagulation. No: emergency surgery (Heart Team).
- If Yes
12Action Mechanical valve: optimise anticoagulation
Restart warfarin; continue IV UFH until the INR is in target. DOACs are contraindicated with mechanical valves.
- Find and correct the cause: missed doses, interactions, diet, alcohol, illness
- Thrombus or embolism with INR already in range: raise the INR target or add aspirin 100 mg daily, if bleeding risk allows
- Raise INR goal: aortic from 2.5 to 3.0 (range 2.5-3.5); mitral from 3.0 to 4.0 (range 3.5-4.0)
- Repeat TEE or CT to check that the thrombus resolves
13Action Follow-up after treatment
Reimage until the thrombus has resolved
- Thrombus persists with obstruction or embolism: Heart Team review
- Mechanical valve: lifelong warfarin; INR self-testing for trained patients
- Bioprosthetic valve: thrombosis can recur; consider longer anticoagulation against bleeding risk
- Educate on adherence, interactions and INR checks
14Outcome Thrombus resolved, valve function restored
Continue anticoagulation and INR monitoring
If No15Action Surgery: emergency redo valve replacement or thrombectomy
Surgery chosen, lysis failed, or large thrombus with embolism
- Redo valve replacement, or thrombectomy if the valve can be saved
- 30-day surgical mortality 10-15%; below 5% if NYHA I-II
- Restart anticoagulation after surgery per the cardiac surgical team
- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 15Shared downstream outcome
If No16Decision No symptomatic obstruction: thrombus 10 mm or more with embolism?
Yes: consider surgery. No: optimise anticoagulation and reimage.
- If Yes
17Action Large thrombus (10 mm or more) with embolism: consider surgery
Heart Team decision. Surgery is also an option if the thrombus persists despite optimal anticoagulation.
- Optimise anticoagulation while the team decides
- Surgery not suitable: Heart Team plan (anticoagulation or low-dose lysis)
- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 12Shared downstream outcome
If No18Action Bioprosthetic valve (surgical or TAVI): warfarin first
Stable patient: warfarin (VKA) before any reintervention. Stroke symptoms: CT brain first; neurology decides timing. Unstable or worsening heart failure: urgent Heart Team.
- Warfarin first line: ESC/EACTS 2025 Class I, ACC/AHA 2020 Class 2a
- Unstable: urgent reintervention (redo surgery) or lysis (Heart Team)
- Leaflet thickening with raised gradients on CT: anticoagulate at least until resolution
- Do not use mechanical-valve INR targets, added aspirin or lysis as the default
- Reimage (TTE, CT or TEE) to confirm resolution
- Path rejoins step 13Shared downstream outcome
Guideline Source
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease (Sections 11.6-11.7); with 2025 ESC/EACTS Guidelines for the management of valvular heart disease (Section 14.4.4)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Surgery or lysis for obstructive thrombosis is a Heart Team decision; local surgical expertise matters.
- Adults only. Pregnancy and children need specialist cardiology and cardiac surgery advice.
- Low-dose slow alteplase evidence is observational (TROIA, PROMETEE, HATTUSHA); no randomised trial.
- DOACs are contraindicated with mechanical valves.
Contraindicated Populations
Children (paediatric cardiology and cardiac surgery advice)Pregnancy (cardiology, cardiac surgery and obstetric team)
Applicable Regions
USEUAU
AU: Alteplase (Actilyse) is on the ARTG. Low-dose aspirin is 100 mg in Australia. Warfarin is the VKA. No Australian PVT guideline; ACC/AHA and ESC/EACTS are used.
EU: ESC/EACTS 2025: Heart Team choice of surgery or slow low-dose fibrinolysis for obstructive mechanical PVT with NYHA III-IV (Class I); the 2021 accelerated regimen is no longer listed.
US: ACC/AHA 2020: slow-infusion low-dose fibrinolysis or emergency surgery, both Class 1, for symptomatic left-sided mechanical PVT.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Prosthetic Valve Thrombosis Management (ACC/AHA 2020, ESC/EACTS 2025)?
The Prosthetic Valve Thrombosis Management (ACC/AHA 2020, ESC/EACTS 2025) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease (Sections 11.6-11.7); with 2025 ESC/EACTS Guidelines for the management of valvular heart disease (Section 14.4.4).
What guideline is the Prosthetic Valve Thrombosis Management (ACC/AHA 2020, ESC/EACTS 2025) based on?
This algorithm is based on 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease (Sections 11.6-11.7); with 2025 ESC/EACTS Guidelines for the management of valvular heart disease (Section 14.4.4) (DOI: 10.1161/CIR.0000000000000923).
What are the limitations of the Prosthetic Valve Thrombosis Management (ACC/AHA 2020, ESC/EACTS 2025)?
Known limitations include: Surgery or lysis for obstructive thrombosis is a Heart Team decision; local surgical expertise matters.; Adults only. Pregnancy and children need specialist cardiology and cardiac surgery advice.; Low-dose slow alteplase evidence is observational (TROIA, PROMETEE, HATTUSHA); no randomised trial.; DOACs are contraindicated with mechanical valves.. Individual patient factors may require deviation from these recommendations.
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