Prosthetic heart valves: choice, anticoagulation and thrombosis

This page covers life with a valve prosthesis, from the choice of valve to its failure.^[1] It takes in INR targets, the rows that bar DOACs, bridging, follow-up imaging and valve thrombosis.^[1] It also covers structural valve deterioration (SVD), prosthesis–patient mismatch (PPM), and pointers on endocarditis and pregnancy.^[1][6][7] The native lesions have their own pages: Aortic stenosis: severity grading and TAVI vs SAVR and Mitral regurgitation: primary vs secondary, repair vs replacement, TEER. Prosthetic valve endocarditis is covered in Infective endocarditis: Duke criteria, imaging, surgery.

Overview and definitions

Picture a 58-year-old who needs an aortic valve replacement and asks which valve to have. ESC/EACTS 2025 frames the trade-off plainly: MHVs are durable but require long-term anticoagulation, with associated thromboembolic and bleeding risks.^[1] BHVs do not require long-term anticoagulation but have limited durability that varies between devices and is inversely associated with age.^[1]

Every prosthesis then needs watching.^[1] ESC/EACTS 2025 says all patients with prosthetic valves require lifelong clinical and echocardiographic follow-up to detect deterioration of prosthetic function, associated cardiac damage, or progressive disease of another valve.^[1]

The words used for a failing valve

ESC/EACTS 2025 separates two kinds of prosthetic valve dysfunction.^[1] One is intrinsic permanent change to the prosthesis, defined as SVD.^[1] The other is non-structural valve dysfunction, from any abnormality not intrinsic to the prosthesis itself.^[1] It treats valve thrombosis and endocarditis as separate entities, because of their specific presentation and management, but says both may result in SVD.^[1] It says SVD has been defined by several consensus documents and includes wear and tear, leaflet disruption, leaflet fibrosis or calcification, and stent or strut fracture or deformation.^[1]

ESC/EACTS 2025 counts prosthesis–patient mismatch among the causes of non-structural valve dysfunction.^[1] ACC/AHA 2020 says that in some patients the orifice area of the implanted prosthesis may be inadequate to meet the cardiac output demands of the patient, and calls this PPM.^[3] This can happen even when the prosthetic valve itself is functioning normally.^[3] It says PPM is associated with a high transvalvular gradient, persistent LV hypertrophy and an increased rate of cardiac events after valve replacement.^[3]

Choosing a mechanical or a biological valve

Start with the patient and only then look at the age lines. ESC/EACTS 2025 says age, life expectancy, lifestyle, bleeding and thromboembolic risks, possibility of pregnancy, and patient preference should be considered.^[1] Life expectancy is estimated according to age, sex, comorbidities, ethnicity and geographical area.^[1] ACC/AHA 2020 recommends that the choice rest on a shared decision-making process that accounts for the patient's values and preferences (COR 1, LOE C-LD).^[3] That process includes discussion of the indications for and risks of anticoagulant therapy, and of the potential need for and risks of valve reintervention.^[3]

ESC/EACTS 2025 says an MHV is preferred in younger patients with longer life expectancy and in those with a pre-existing indication for long-term oral anticoagulation (OAC).^[1] It says a BHV is generally implanted in patients with shorter life expectancy or increased bleeding risk due to frailty or comorbidities.^[1] The same applies to women contemplating pregnancy, and to patients in whom stable INRs with adequate times in therapeutic range are unlikely.^[1] It adds that the performance of different BHV prostheses can vary considerably.^[1]

ESC/EACTS 2025 Recommendation Table 13: prosthetic valve selection

^[1]

The table footnote says life expectancy should be estimated according to age, sex, comorbidities, ethnicity and geographical area.^[1]

ACC/AHA 2020: bioprosthetic versus mechanical valve (JACC co-publication rows)

^[3]

The levels above are those printed in the prosthetic valve section; the same document prints the under-50 and over-65 AVR rows as COR 2a, LOE B-R in its aortic stenosis section.^[3]

Notice where the two regions disagree. The age lines are not the same, and the US mitral rows carry their own conditions.^[1][3]

• Aortic, ESC/EACTS 2025: an MHV should be considered in patients aged under 60 years and a BHV should be considered in patients aged over 65 years (Class IIa, Level C for each).^[1]
• Aortic, ACC/AHA 2020: when AVR is needed and there is no contraindication to anticoagulation, it is reasonable to choose a mechanical prosthesis under 50 years and to individualise the choice from 50 to 65 years, with consideration of individual patient factors and after informed shared decision-making; over 65 years it is reasonable to choose a bioprosthesis (each COR 2a, LOE B-NR).^[3]
• Mitral, ESC/EACTS 2025: an MHV should be considered under 65 years and a BHV over 70 years (Class IIa, Level C).^[1]
• Mitral, ACC/AHA 2020: for patients who need mitral valve replacement and are unable to undergo mitral valve repair, it is reasonable to choose a mechanical prosthesis under 65 years if there is no contraindication to anticoagulation, and a bioprosthesis at 65 years or older (each COR 2a, LOE B-NR).^[3]

ACC/AHA 2020 Table 22: selected factors that may impact shared decision-making for the choice of prosthetic valve

^{[2] [3] [1]}

What the evidence on age can and cannot tell you

ESC/EACTS 2025 reports that several large observational studies, smaller RCTs and meta-analyses have compared long-term mortality with BHV and MHV prostheses in patients aged 50–70 years.^[1] Some showed lower mortality with an MHV in aortic valve patients under 60 years and mitral valve patients under 65 years.^[1] Others failed to show any differences.^[1] It says most of these studies were limited by their observational nature and missing information on the type of prostheses implanted.^[1] It calls for RCTs with sufficient statistical power comparing biological and mechanical prostheses.^[1]

ACC/AHA 2020 puts numbers on bioprosthetic durability.^[2] It gives a predicted 15-year risk of needing reoperation because of structural deterioration of 22% for patients 50 years of age, 30% at 40 years and 50% at 20 years.^[2] It also recognises that all bioprostheses are not alike in durability.^[2] In patients over 65 at the time of bioprosthetic AVR, it says the likelihood of primary structural deterioration at 15 to 20 years is only about 10%.^[2]

Ross procedure and lifetime planning

ESC/EACTS 2025 calls the Ross procedure (aortic valve replacement with an autograft) an alternative to an MHV in young patients.^[1] It says the operation should be performed at experienced centres by operators with dedicated expertise.^[1] ACC/AHA 2020 says the Ross procedure may be considered at a Comprehensive Valve Center in patients under 50 who prefer a bioprosthetic AVR and have appropriate anatomy (COR 2b, LOE B-NR).^[3] It adds that a mechanical valve might be a prudent choice when a second operation would be very high risk, such as after prior radiation exposure.^[2]

Lifetime planning also covers the next valve.^[1] In its aortic stenosis chapter, ESC/EACTS 2025 lists measures that should be considered, based on individual assessment, for lifetime management, and says a meticulous CT-based anatomical analysis is paramount when estimated life expectancy exceeds the assumed valve durability.^[1] One is SAVR with aortic root enlargement, or a supra-annular transcatheter valve, in patients with a small annulus at risk of severe PPM based on the predicted effective orifice area (EOA).^[1] Choosing between TAVI and SAVR is covered in Aortic stenosis: severity grading and TAVI vs SAVR; mitral repair versus replacement in Mitral regurgitation: primary vs secondary, repair vs replacement, TEER.

Anticoagulation for a mechanical valve

This is the part examiners test hardest. ESC/EACTS 2025 says lifelong VKA is recommended for all patients with an MHV to avoid major thrombotic complications.^[1] Its reason is that cardioembolic or valve thrombosis rates without anticoagulation are substantial: 12% per year and 22% per year for first-generation aortic and mitral MHVs, respectively.^[1] ACC/AHA 2020 recommends anticoagulation with a VKA in patients with a mechanical prosthetic valve (COR 1, LOE A).^[3]

ESC/EACTS 2025 Recommendation Table 14: antithrombotic therapy with a mechanical heart valve

^[1]

INR targets

ESC/EACTS 2025 Table 10: international normalized ratio targets and therapeutic ranges for patients with a mechanical heart valve (first-line treatment with VKA only)

^[1]

Table 10 lists four additional pro-thrombotic factors.^[1] They are an inherited or acquired hypercoagulable state, LV dysfunction (LVEF under 35%), and AF with significant mitral stenosis (MS).^[1] The fourth is a recent (under 12 months) major thrombotic event: cardioembolic stroke, deep vein thrombosis or pulmonary embolism.^[1] ESC/EACTS 2025 says the INR target and range should be chosen considering the type, position and number of valves, the patient's thrombotic risk and comorbidities.^[1]

ACC/AHA 2020: antithrombotic rows for mechanical valves

^[3]

ACC/AHA 2020 says it is preferable to specify a single INR target for each patient.^[2] The acceptable range then includes 0.5 INR units on each side of that target.^[2] It says fluctuations in INR are associated with an increased incidence of complications in patients with prosthetic heart valves.^[2]

Watch AF in a mechanical aortic valve, because the two regions list it differently.^[3][1] ACC/AHA 2020 gives AF as an example of the added thromboembolic risk factors for which a VKA is indicated to an INR of 3.0 with a mechanical AVR (COR 1, LOE B-NR).^[3] ESC/EACTS 2025 Table 10 lists AF with significant MS, rather than AF alone, among its additional pro-thrombotic factors.^[1]

^[1]

Why DOACs are barred

The European and US valve guidelines bar DOACs with a mechanical valve.^[1][3] The ESC 2024 AF guideline excepts mechanical heart valves from its DOAC-preference row and says DOACs as a class should be avoided in specific patient groups, such as those with mechanical heart valves.^[4] The ACC/AHA/ACCP/HRS 2023 AF guideline excludes mechanical heart valves from its DOAC row and names VKAs as the anticoagulants of choice for patients with mechanical heart valves.^[5] ESC/EACTS 2025 says DOACs or DAPT are contraindicated to prevent thromboembolism in patients with an MHV.^[1] Its formal row says DOACs and/or DAPT are not recommended to prevent thrombosis in patients with an MHV (Class III, Level A).^[1] ACC/AHA 2020 says anticoagulation with the direct thrombin inhibitor dabigatran is contraindicated with a mechanical valve prosthesis (COR 3: Harm, LOE B-R).^[3] It says the use of anti-Xa DOACs with a mechanical valve prosthesis has not been assessed and is not recommended (COR 3: Harm, LOE C-EO).^[3]

The trials explain the rows. ACC/AHA 2020 reports that RE-ALIGN, a randomised phase II comparison of dabigatran with warfarin after heart valve replacement, was stopped prematurely.^[2] The reason was excessive thrombotic and bleeding complications in the dabigatran arm.^[2] The 2024 ESC AF guideline reports that a trial of apixaban versus VKA after mechanical aortic valve implantation was also stopped, because of excess thromboembolic events with apixaban.^[4] ACC/AHA 2020 says the safety and efficacy of conventional-dose oral anti-Xa agents with a mechanical valve prosthesis have not been evaluated.^[2]

Atrial fibrillation does not change this.^[4] ESC 2024 AF recommends DOACs in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to-severe mitral stenosis (Recommendation Table 7, Class I, Level A).^[4] It says VKAs are currently the only treatment option in AF patients with mechanical heart valves or moderate-to-severe mitral valve stenosis.^[4] ACC/AHA/ACCP/HRS 2023 AF recommends DOACs over VKAs in AF with valve disease other than moderate or greater mitral stenosis or a mechanical heart valve (COR 1, LOE B-NR).^[5] Wider AF anticoagulation is covered in Atrial fibrillation.

Antiplatelets, thromboembolism on target and bleeding

ESC/EACTS 2025 says the combination of antiplatelet agents (single or dual) with a VKA increases the risk of bleeding.^[1] Their use should therefore be carefully weighed.^[1] It refers the VKA and DAPT combination in MHV patients presenting with acute coronary syndrome to the corresponding ESC Guidelines.^[1]

When a stroke or embolism happens on target, two regions answer in similar terms.^[1][3] The ACC/AHA 2020 synopsis says that, for patients with a mechanical valve who suffer an embolic event, it is important to assess the adequacy of VKA anticoagulation and document time spent in the therapeutic range.^[3] It also says to exclude infective endocarditis, screen for new-onset AF and consider whether an underlying hypercoagulable state might be contributing.^[3]

• ESC/EACTS 2025: either an increase in INR target or the addition of low-dose aspirin (75–100 mg/day) should be considered in patients with MHVs who develop a major thromboembolic complication despite documented adequate INR (Class IIa, Level C); its text gives time in therapeutic range (TTR) as usually defined as over 60%.^[1]

• ACC/AHA 2020, mechanical AVR: after a stroke or systemic embolic event while in therapeutic range on a VKA, it is reasonable to raise the INR goal from 2.5 (range 2.0–3.0) to 3.0 (range 2.5–3.5) or to add daily low-dose aspirin (75–100 mg), with assessment of bleeding risk (COR 2a, LOE C-EO).^[3]

• ACC/AHA 2020, mechanical mitral valve replacement: in the same situation it is reasonable to raise the INR goal from 3.0 (range 2.5–3.5) to 4.0 (range 3.5–4.0) or to add daily low-dose aspirin (75–100 mg), with assessment of bleeding risk (COR 2a, LOE C-EO).^[3]

• Gastric protection (ESC/EACTS 2025): proton pump inhibitors reduce the risk of upper gastrointestinal bleeding by approximately 40% in patients taking VKAs and should therefore be prescribed to patients with MHVs, particularly with additional bleeding risk factors (for example elderly, antiplatelet co-administration, chronic NSAID use, high INR, or alcohol abuse).^[1]

• High INR, not bleeding (ESC/EACTS 2025): RCTs and a meta-analysis did not show a benefit of oral vitamin K1 added to temporary VKA cessation in non-bleeding patients with an INR of 4.5–10.0, with a trend toward reduced safety, which may be relevant for MHV patients; with an INR over 10.0, oral vitamin K1 (2.0–3.0 mg) should be given, avoiding overcorrection.^[1]

• High INR, not bleeding (ACC/AHA 2020): with a mechanical valve and an INR over 5.0 without active bleeding, the benefit of individualised oral vitamin K in addition to temporary VKA withdrawal is uncertain (COR 2b, LOE C-LD).^[3]

• Major bleeding (ESC/EACTS 2025): in uncontrolled life-threatening or other major bleeding, VKA must be interrupted, and reversal with non-activated four-factor prothrombin complex concentrate (PCC) is preferred over fresh frozen plasma because of higher safety and effectiveness; vitamin K1 should also be given, and VKA restarted as soon as major bleeding is controlled.^[1]

• PCC dose (ESC/EACTS 2025): a reduced starting dose (12.5 rather than 25 IU/kg) may be considered with more thrombogenic MHVs.^[1]

• Major bleeding (ACC/AHA 2020): with a mechanical valve and uncontrollable bleeding needing immediate reversal, 4-factor PCC (or its activated form) is reasonable (COR 2a, LOE C-LD); adjunctive intravenous vitamin K is reasonable if VKA resumption is not anticipated for 7 days (COR 2a, LOE C-LD).^[3]

Antithrombotic therapy after a biological valve or TAVI

ESC/EACTS 2025 says the optimal antithrombotic strategy early after surgical implantation of an aortic BHV remains controversial due to the lack of high-quality evidence.^[1] It reports a small RCT and a meta-analysis in which 3 months of VKA significantly increased major bleeding compared with low-dose aspirin.^[1] VKA did not reduce mortality or thromboembolic events, but statistical power was low.^[1]

ESC/EACTS 2025 Recommendation Table 16: antithrombotic therapy with a biological valve (rows used here)

^[1]

ESC/EACTS 2025 explains its TAVI rows for patients without an indication for OAC through two trials.^[1] It reports that in POPular TAVI (cohort A), bleeding and the composite of bleeding or thromboembolic events were both reduced with aspirin compared with DAPT at 1 year.^[1] It reports that GALILEO, an RCT after TAVI, compared rivaroxaban 10 mg/day plus low-dose aspirin with DAPT with clopidogrel for the first 3 months.^[1] It reports that the trial was halted prematurely because of increased risks of death or thromboembolic complications, and of bleeding, in the rivaroxaban/aspirin group.^[1] It therefore says systematic use of DOACs after TAVI in patients without an indication for OAC is not recommended.^[1] With a pre-existing indication for OAC after TAVI, it says no definitive recommendation can be made on VKAs versus DOACs.^[1]

ACC/AHA 2020: antithrombotic rows for bioprosthetic valves

^[3]

Here the European and US rows differ after TAVI.^[1][3] ESC/EACTS 2025 says DAPT is not recommended to prevent thrombosis after TAVI unless there is a clear indication (Class III, Level B).^[1] ACC/AHA 2020 says DAPT with aspirin and clopidogrel may be reasonable for 3 to 6 months after a bioprosthetic TAVI at low risk of bleeding (COR 2b, LOE B-NR).^[3]

Bioprostheses and AF are where DOACs come back.^[4][1] ESC 2024 AF says the restriction on DOAC use does not apply to bioprosthetic heart valves (including mitral) or after TAVI.^[4] There, it says, DOACs can be used, and trial data show non-inferiority for clinical events compared with VKAs.^[4] For patients with a surgical BHV, ESC/EACTS 2025 says the evidence supports DOACs in preference to VKAs in patients with AF, even during the early post-operative period.^[1] A previously existing DOAC may be continued after BHV implantation and should be restarted as soon as considered surgically safe, usually within 2–3 days of surgery.^[1] ACC/AHA 2020 says many patients who develop an indication for anticoagulation late after bioprosthetic valve replacement or native valve repair are treated safely with DOACs.^[2] That use is predicated on their CHA₂DS₂-VASc score and predicted bleeding risk.^[2]

Procedures and bridging

The question is always two-sided: how big is the bleed risk of the procedure, and how thrombogenic is the valve?^[2][1] ACC/AHA 2020 says interruption should take into account the type and location of the valve, the type of procedure and thromboembolic risk factors.^[2] It adds how long oral anticoagulation will be withheld, and bleeding risk.^[2]

ESC/EACTS 2025 Recommendation Table 15: MHV and elective non-cardiac surgery or invasive procedures

^[1]

• Minor interventions (footnote c): skin; minor eye surgery including cataract; dental cleaning, treatment of caries and dental extractions; pacemaker or device implantation; diagnostic cardiac catheterisation; and gastroscopic, colonoscopic, bronchoscopic or genitourinary diagnostic or therapeutic procedures considered at low bleeding risk.^[1]
• Bridging timing (footnote d): bridging needs to be started as soon as the INR reaches a subtherapeutic value and on the first post-operative day or as soon as considered safe.^[1]
• Thromboembolic risk factors (footnote e): an MHV in the mitral or tricuspid position, older MHV generations in any position, an inherited or acquired hypercoagulable state, LV dysfunction (LVEF under 35%), AF with significant MS, and a recent (under 12 months) major thrombotic event (cardioembolic stroke, deep vein thrombosis or pulmonary embolism).^[1]

ESC/EACTS 2025 Table 11 (major procedures): peri-operative antithrombotic management with an MHV

^[1]

For minimally invasive procedures, Table 11 gives no interruption of VKA before and continued VKA after, in both risk groups.^[1] Topical antifibrinolytic or haemostatic agents may be considered to improve local haemostasis.^[1] Its moderate-to-high-risk pre-procedure bridging cell is printed as quoted above.^[1]

ESC/EACTS 2025 text spells out the high-risk sequence.^[1] It covers an MHV with high thromboembolic risk undergoing non-cardiac, elective major invasive procedures with high bleeding risk.^[1] VKA must be interrupted at least 4 days before, and bridging with LMWH should start as soon as the INR reaches a subtherapeutic value.^[1] The INR should be under 1.5 on the day of surgery.^[1] It says measuring anti-Xa activity at peak and trough may be appropriate to manage LMWH dosing in selected patients, such as those with severe obesity or underweight.^[1] For urgent major invasive procedures, it says four-factor PCC should be given to correct the INR in time, if needed.^[1]

ACC/AHA 2020: bridging during interruption of oral anticoagulation

^[3]

ACC/AHA 2020 supportive text gives the timing.^[2] VKA is usually stopped 3 to 4 days before the procedure and restarted as soon as bleeding risk allows.^[2] Bridging with intravenous UFH or subcutaneous LMWH starts when the INR falls below the therapeutic threshold (2.0 or 2.5, depending on the clinical context), usually 36 to 48 hours before surgery.^[2] It stops 4 to 6 hours (intravenous UFH) or 12 hours (subcutaneous LMWH) before the procedure.^[2] In the low-risk bileaflet aortic group, it says VKA is stopped 2 to 4 days before and restarted as soon as bleeding risk allows, typically 24 hours after surgery.^[2] It says no randomised comparative-effectiveness trials have tested bridging against no bridging in adequate numbers of patients with prosthetic valves who need temporary interruption of oral anticoagulant therapy, although it said such studies were ongoing.^[2] Decisions about bridging should therefore be individualised and account for the trade-offs between thrombosis and bleeding.^[2]

For a bileaflet mechanical AVR with AF, the ACC/AHA 2020 valve guideline reads as follows.^[3] It gives AF as an example of the added thromboembolic risk factors for which, with a mechanical AVR, a VKA is indicated to achieve an INR of 3.0 (COR 1, LOE B-NR).^[3] Its bridging row 5 covers invasive procedures with a mechanical AVR and any thromboembolic risk factor, an older-generation mechanical AVR, or a mechanical mitral valve replacement.^[3] In those patients, it finds bridging during the preoperative interval when the INR is subtherapeutic reasonable on an individualised basis, weighing bleeding against thromboembolism prevention (COR 2a, LOE C-LD).^[3]

In its periprocedural management section, the ACC/AHA/ACCP/HRS 2023 AF guideline says patients with mechanical valves should be managed as outlined in the 2020 ACC/AHA valvular heart disease guideline.^[5]

Dated history: the 2024 AHA/ACC perioperative guideline

Before its 2026 edition, the AHA/ACC multisociety guideline on perioperative cardiovascular management for noncardiac surgery also covered bridging, in its 2024 edition.^[9] That 2024 edition is superseded by a 2026 edition (PMID 42804570, published September 2026), which is not held as text for this topic, so any newer US peri-procedural rows for prosthetic valves in it could not be checked. The 2024 text below is given only as dated history; no current US row is taken from it.

Among its top take-home messages, the 2024 edition stated that perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at highest risk for thrombotic complications and is not recommended in the majority of cases.^[9] Its section on oral anticoagulants (Section 7.6) stated that in high thrombotic risk patients receiving a VKA, bridging with parenteral anticoagulation is a common practice, but data supporting its efficacy (prevention of thromboembolism) or safety (bleeding) are not available.^[9] It went on to say that, although further RCTs are warranted, available data support limiting the use of bridging to very high thrombotic risk patients on a VKA (for example, mechanical mitral valves).^[9] The same sentence added careful consideration of bleeding risk (for example HAS-BLED, previous personal bleeding history and perioperative bleeding risk) to determine an individualised strategy.^[9]

Dated history, AHA/ACC 2024 perioperative guideline (superseded by the 2026 edition) Table 14: thromboembolic risk for common oral anticoagulant indications (Mechanical Valve column)

^[9]

Its Table 14 footnote stated that major risk factors for stroke include AF, multiple prior strokes or TIAs (≥3 months), prior perioperative stroke, or prior valve thrombosis.^[9] In the Mechanical Valve column of that superseded table, a bileaflet mechanical AVR with major risk factors for stroke, AF among them, was in the moderate category.^[9] Its Section 7.6 recommendation rows, with their COR and LOE, are printed as an image in the copy held for this topic and no text copy was found, so no class is given here for them.

Straight after valve surgery

ESC/EACTS 2025 recommends starting UFH or LMWH bridging and VKA within 24 h after cardiac surgery with MHV implantation, or as soon as considered safe (Class I, Level B).^[1] Its text says heparin can be stopped when the INR is documented for 2 consecutive days within the therapeutic range.^[1] It reports that two meta-analyses and a prospective study suggested slightly lower bleeding rates with UFH than with LMWH bridging after MHV replacement or cardiac surgery.^[1] It adds that RCTs comparing the timing and dosage of each bridging strategy are lacking.^[1]

^[1]

Follow-up imaging

Start with the baseline study. ACC/AHA 2020 recommends an initial post-procedural TTE after a surgical or transcatheter prosthetic valve or valve repair, to evaluate valve haemodynamics and ventricular function (COR 1, LOE B-NR).^[3] In its aortic stenosis follow-up section, ESC/EACTS 2025 says that after valve intervention, an early echocardiographic examination within the first weeks after valve replacement is recommended to document baseline prosthetic valve function.^[1]

Surveillance imaging after valve replacement

^{[1] [3] [2]}

Why so much attention after the first decade? ACC/AHA 2020 reports that studies based on TTE follow-up estimate that approximately 30% of patients with a surgical aortic valve bioprosthesis develop evidence of valve dysfunction over the 10 years after implantation.^[2] Dysfunction is defined there as an increase in mean gradient of 10 mm Hg or more, or worsening transprosthetic regurgitation from mild to moderate or from moderate to severe.^[2] Risk factors for accelerated (under 5 years) deterioration include young age (under 60 years) at implantation, smoking, diabetes mellitus and chronic kidney disease.^[2] An initial mean gradient of 15 mm Hg or more and valve type are also on its list.^[2] It says TAVI-based protocols typically include routine TTE before discharge and at 30 days and 1 year, partly because of reporting requirements.^[2]

Transthoracic echo has a blind spot on the left atrial side of a mitral prosthesis.^[2] ACC/AHA 2020 says acoustic shadowing on TTE obscures the left atrial side of a prosthetic mitral valve.^[2] That reduces sensitivity for prosthetic MR and for prosthetic mitral thrombus, pannus or vegetation.^[2] ESC/EACTS 2025 says cinefluoroscopy for MHVs and cardiac CT (CCT) provide useful additional information if valve thrombus or pannus is suspected.^[1]

^{[3] [1]}

Prosthetic valve thrombosis

ESC/EACTS 2025 says valve thrombosis occurs mainly in MHVs but can also be observed in BHVs.^[1] ACC/AHA 2020 says mechanical valve thrombosis is typically a subacute to acute event causing rapid valve dysfunction from abnormal or absent leaflet motion.^[3] It says this is often associated with inadequate VKA anticoagulation.^[3] It gives the annual rate of prosthetic valve thrombosis with mechanical valves as 0.1% to 5.7%.^[3]

When to suspect it

ESC/EACTS 2025 says obstructive valve thrombosis should be suspected in any patient with any type of prosthetic valve who presents with one of three things.^[1] They are new-onset dyspnoea or heart failure (HF) symptoms, an embolic event, or an unexpected increase in transvalvular gradients.^[1] ACC/AHA 2020 says examination may show a stenotic murmur and muffled closing clicks, and that further urgent diagnostic evaluation is required.^[3] It says patients with mechanical valve dysfunction may present with HF, shock, thromboembolic events, haemolysis, or a change in auscultatory findings.^[2]

Confirming it

• ESC/EACTS 2025: TOE and/or 4D-CT are recommended in suspected valve thrombosis to confirm the diagnosis (Class I, Level C). Its text adds that if TTE findings are uncertain, TOE and/or CCT should distinguish thrombus, pannus and degeneration, and that cinefluoroscopy can detect impaired MHV leaflet motion and reduced opening angles (no class or level given).^[1]
• ACC/AHA 2020: in suspected mechanical valve thrombosis, urgent evaluation with TTE, TEE, fluoroscopy and/or multidetector CT is indicated to assess valve function, leaflet motion, and the presence and extent of thrombus (COR 1, LOE B-NR).^[3]
• ACC/AHA 2020 obstruction threshold: prosthetic valve obstruction is usually defined as a mean transvalvular gradient increase over 50% (or an increase over 10 mm Hg across an aortic prosthesis) compared with baseline, after exclusion of other causes such as a high-output state.^[3]

Treating mechanical valve thrombosis

ESC/EACTS 2025 says adequate anticoagulation must be promptly restored in all patients with MHV thrombosis and a subtherapeutic INR.^[1] It says surgery remains the first-line option in critically ill patients, although emergency valve replacement is associated with increased risk.^[1] Bleeding and systemic embolism are increased with fibrinolysis.^[1] Slow, low-dose infusion appears to lower complication rates while preserving thrombolytic success rates.^[1] Its formal row recommends Heart Team evaluation in acute HF (NYHA class III or IV) due to obstructive MHV thrombosis, to determine appropriate management (repeat valve replacement or low-dose slow-infusion fibrinolysis) (Class I, Level B).^[1] For a large (over 10 mm) prosthetic thrombus complicated by embolism, surgery should be considered (Class IIa, Level C).^[1] Its text extends this to a large non-obstructive thrombus that persists despite optimal OAC.^[1]

ACC/AHA 2020 recommends urgent initial treatment with either slow-infusion, low-dose fibrinolytic therapy or emergency surgery for a thrombosed left-sided mechanical valve with symptoms of valve obstruction (COR 1, LOE B-NR).^[3] It gives an overall 30-day mortality with surgery of 10% to 15%, and under 5% with NYHA class I or II symptoms.^[3] It reports that recent studies using an echocardiogram-guided, slow-infusion, low-dose fibrinolytic protocol have shown haemodynamic success rates over 90%.^[3] Embolic event rates and major bleeding rates were each under 2% in those studies.^[3]

ACC/AHA 2020 Table 23: systemic fibrinolysis versus surgery for prosthetic valve thrombosis

^[3]

ESC/EACTS 2025 says imaging should be repeated after thrombolytic and antithrombotic treatment of MHV thrombosis (printed "MVH thrombosis" in the source), even if gradients are normalised.^[1]

Bioprosthetic valve thrombosis and leaflet thickening

ESC/EACTS 2025 says BHV thrombosis ranges from incidental CCT findings to clinically apparent presentations.^[1] The incidental end includes hypo-attenuated leaflet thickening (HALT), with or without reduced leaflet motion but normal gradients.^[1] The apparent end brings elevated gradients, symptoms of valve obstruction, or thromboembolic events.^[1] It reports HALT on CCT in 10%–30% of aortic BHVs, depending on antithrombotic management, the definition of HALT, the timepoint of assessment and the valve type.^[1] The significance of these findings for thromboembolic risk and valve durability remains uncertain, so routine use of CCT to detect HALT is not indicated.^[1] ACC/AHA 2020 says bioprosthetic valve thrombosis is most common in the first 3 months after implantation.^[3] It has also been described years later (typically 1 or 2), with the longest interval being 6.5 years.^[3]

• ESC/EACTS 2025: OAC using a VKA is recommended in BHV thrombosis before considering reintervention (Class I, Level B); OAC should be considered with leaflet thickening and reduced leaflet motion leading to elevated gradients, at least until resolution (Class IIa, Level B).^[1]
• ESC/EACTS 2025 text: VKA is the first-line treatment for clinically relevant BHV thrombosis unless urgent reintervention or fibrinolysis is required for progressive acute HF or haemodynamic instability; because it is associated with recurrence and may contribute to prosthetic degeneration, indefinite anticoagulation may be considered after a confirmed episode, balanced against the risk of bleeding.^[1]
• ACC/AHA 2020: in suspected bioprosthetic valve thrombosis, 3D TEE or 4D CT can be useful to rule out leaflet thrombosis (COR 2a, LOE C-LD); with suspected or confirmed bioprosthetic valve thrombosis in a haemodynamically stable patient with no contraindication to anticoagulation, initial VKA treatment is reasonable (COR 2a, LOE B-NR).^[3]

^[1]

Structural valve deterioration and prosthesis failure

ESC/EACTS 2025 says BHV (transcatheter or surgical) SVD is more frequent than MHV SVD.^[1] It says the incidence of SVD may be underestimated by simple analysis of patients with valve-related deaths or those undergoing reintervention.^[1] To ensure timely diagnosis, it says serial measurements should be performed and compared with the TTE performed at discharge, or within 1–3 months after valve implantation.^[1]

ESC/EACTS 2025 Table 12 (aortic BHV): moderate or severe haemodynamic valve deterioration

^[1]

ESC/EACTS 2025 Table 12 (mitral BHV): moderate or severe haemodynamic valve deterioration

^[1]

Table 12 applies its criteria to SVD or non-structural valve dysfunction (except paravalvular leak or PPM), thrombosis, or endocarditis.^[1] Its footnotes on non-structural dysfunction name obstruction by pannus, dilatation of the aortic root after a stentless BHV, or aortic-valve-sparing operations for aortic BHVs.^[1] For mitral BHVs they name leaflet entrapment by pannus, chordae or suture.^[1]

What happens after the diagnosis? ESC/EACTS 2025 says moderate or severe haemodynamic deterioration should prompt referral to an experienced Heart Valve Centre for evaluation and treatment.^[1] All causes of non-structural valve dysfunction should be excluded, particularly paravalvular leak (PVL) or PPM, as well as thrombosis and endocarditis.^[1] This step requires advanced imaging (TOE, CCT and/or PET-CT) to document SVD-related morphological changes and elucidate the mechanism.^[1] SVD with corresponding clinical criteria, such as new or worsening symptoms, LV or RV dilatation or dysfunction, or pulmonary hypertension, indicates BHV failure with potential need for reintervention.^[1] The choice between redo surgery and transcatheter valve-in-valve implantation should be made within the interdisciplinary Heart Team.^[1]

ESC/EACTS 2025 Recommendation Table 17, mechanical and biological heart valve failure rows: recommendations for the management of prosthetic valve dysfunction

^[1]

ACC/AHA 2020 says repeat surgical intervention is indicated in symptomatic severe stenosis of a bioprosthetic or mechanical prosthetic valve, unless surgical risk is high or prohibitive (COR 1, LOE B-NR).^[3] It says a transcatheter ViV procedure at a Comprehensive Valve Center is reasonable for severely symptomatic bioprosthetic aortic stenosis with high or prohibitive surgical risk (COR 2a, LOE B-NR).^[3] For significant bioprosthetic valve stenosis attributable to suspected or documented valve thrombosis, it says oral anticoagulation with a VKA is reasonable (COR 2a, LOE B-NR).^[3] In the mitral position, ESC/EACTS 2025 calls transfemoral or transseptal valve-in-valve implantation an attractive alternative to redo open surgery.^[1] It says the risk of LV outflow tract obstruction, although infrequent, should be carefully ruled out, especially in small and hypertrophic ventricles.^[1]

^[1]

Prosthesis–patient mismatch

Mismatch is a problem of size, even when the valve works.^[3] ACC/AHA 2020 says that in some patients the orifice area of the implanted prosthesis may be inadequate to meet their cardiac output demands, even when the valve is functioning normally.^[3] It links PPM with a high transvalvular gradient, persistent LV hypertrophy and an increased rate of cardiac events after valve replacement.^[3] ESC/EACTS 2025 says PPM should be prevented whenever possible after either transcatheter or surgical valve replacement.^[1]

• Aortic position (ESC/EACTS 2025): severe PPM is associated with decreased quality of life, increased rehospitalisation and reintervention, and possible reduction in long-term survival, although findings are not consistent throughout all studies; moderate PPM is more common but seems to have a limited impact on outcomes.^[1]
• Mitral and tricuspid positions (ESC/EACTS 2025): less is known about the prevalence and consequences of PPM, and established definitions are lacking.^[1]
• Prediction (ESC/EACTS 2025): the projected indexed EOA may be predicted before implantation to avoid severe PPM, although this concept has been challenged.^[1]
• Who is at risk (ESC/EACTS 2025): patients with small annuli in relation to their body stature; annular enlargement allows larger BHVs with SAVR, and supra-annular designs reduce PPM risk with TAVI, although randomised long-term outcome and durability data are pending.^[1]
• Valve-in-valve (ESC/EACTS 2025): valve-in-valve implantation, particularly TAV-in-SAV, increases the risk of severe PPM, which observational studies have linked to adverse outcomes; with a degenerated aortic BHV, the possibility of creating PPM in small valves should be anticipated and may impact intervention or valve selection.^[1]
• Reintervention (ESC/EACTS 2025): PPM is an infrequent indication for reintervention, but reoperation should be considered in symptomatic patients with severe PPM, particularly if the patient is low risk.^[1]

Paravalvular leak and haemolysis

ESC/EACTS 2025 says the diagnosis of PVL requires systematic TOE, because TTE may be inconclusive.^[1] It says haemolytic anaemia can often be detected in patients with prosthetic valves, but rarely leads to symptoms.^[1] It is best assessed by measuring lactate dehydrogenase and haptoglobin levels.^[1]

• ESC/EACTS 2025: the decision between transcatheter and surgical closure of clinically significant PVLs is recommended to rest on Heart Team evaluation, including patient risk, leak morphology and local expertise (Class I, Level C); reoperation is recommended if a PVL is related to endocarditis or causes haemolysis requiring repeated blood transfusion or leading to HF symptoms (Class I, Level C); transcatheter closure should be considered for suitable PVLs with clinically significant regurgitation and/or haemolysis (Class IIa, Level B).^[1]
• ACC/AHA 2020: surgery is recommended for intractable haemolysis or HF attributable to prosthetic transvalvular or paravalvular leak, unless surgical risk is high or prohibitive (COR 1, LOE B-NR).^[3]

Prosthetic valve endocarditis: pointers

Prosthetic valve endocarditis (PVE) has its own page; these are the rows a prosthetic valve clinic needs.^[6] ESC/EACTS 2025 says antibiotic prophylaxis is recommended in all patients with a prosthetic valve, including transcatheter valve prostheses.^[1] It is also recommended after valve repair using prosthetic material or with previous endocarditis, and should be considered after transcatheter mitral or tricuspid repair.^[1] It applies to dental extractions, oral surgery, or other procedures requiring manipulation of the gingival or peri-apical region of the teeth.^[1] Dental and cutaneous hygiene, and strict aseptic measures during any invasive procedure, are also advised.^[1]

• Prophylaxis before oro-dental procedures at increased risk of IE (ESC 2023, Recommendation Table 1): antibiotic prophylaxis is recommended in patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair (Class I, Level C), and in patients with transcatheter implanted aortic and pulmonary valvular prostheses (Class I, Level C).^[6]
• At implantation (ESC 2023): periprocedural antibiotic prophylaxis is recommended in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic or other foreign material (Class I, Level B).^[6]
• Imaging (ESC 2023): [18F]FDG-PET/CT(A) and cardiac CTA are recommended in possible PVE to detect valvular lesions and confirm the diagnosis of IE (Class I, Level B).^[6]
• Imaging (ESC/EACTS 2025 text): TOE is recommended in suspected prosthetic valve endocarditis; CCT and PET-CT are also recommended if the diagnosis is unclear and to identify primary or secondary infection foci (no class or level given).^[1]
• Surgery (ESC 2023, Recommendation Table 19): surgery is recommended for early PVE (within 6 months of valve surgery) with new valve replacement and complete debridement (Class I, Level C).^[6]

ESC/EACTS 2025 says additional details on endocarditis prophylaxis are in the 2023 ESC endocarditis guideline.^[1] Duke criteria, antibiotics and the full surgical rows are in Infective endocarditis: Duke criteria, imaging, surgery.

Pregnancy: pointers

A mechanical valve and a planned pregnancy pull in opposite directions.^[1] In its section on management before pregnancy, ESC/EACTS 2025 says BHVs are recommended when a prosthetic valve is necessary.^[1] It adds that early SVD remains a serious concern.^[1] It says MHVs must be avoided, because of the high risk of maternal and foetal complications linked to the potential teratogenic effects of VKAs, and the increased risk of bleeding.^[1] Its formal valve-selection row says a BHV should be considered in women contemplating pregnancy (Class IIa, Level C).^[1] The ESC 2025 pregnancy guideline recommends a bioprosthetic valve over a mechanical valve in young women contemplating pregnancy who need a valve prosthesis (Class I, Level B).^[7]

• Team and plan (ESC 2025 pregnancy, Recommendation Table 19): the type of valve surgery or intervention for a woman contemplating pregnancy is recommended to be chosen with the Pregnancy Heart Team (Class I, Level C); a care plan documenting the agreed anticoagulant strategy (including continuing VKAs or converting to therapeutic-dose LMWH in the first trimester) is recommended for women of childbearing age with an MHV before pregnancy or as soon as it is recognised (Class I, Level C); pregnant women with an MHV are recommended to be managed by the Pregnancy Heart Team (Class I, Level C).^[7]
• Monitoring (ESC 2025 pregnancy): INR monitoring weekly or at a minimum every 2 weeks on VKAs (Class I, Level C); peak anti-factor Xa levels checked and targeted to individualised risk on therapeutic-dose LMWH (Class I, Level C); LMWH is not recommended when anti-factor Xa monitoring is not available (Class III, Level C).^[7]
• Second and third trimesters (ESC 2025 pregnancy): continuing VKAs until the 36th week should be considered in women with prosthetic heart valves at higher risk of thrombosis (Class IIa, Level C); continuing LMWH with anti-factor Xa monitoring and dose adjustment may be considered in women at lower risk of thrombosis (Class IIb, Level C).^[7]
• Warfarin dose (ESC/EACTS 2025 text): in patients requiring 5 mg/day or less of warfarin, warfarin throughout pregnancy with a change to UFH before delivery is advocated to reduce thrombosis risk; with higher doses, switching to dose-adjusted LMWH at least twice daily with strict anti-Xa monitoring during the first trimester is recommended to avoid VKA teratogenicity (no class or level given).^[1]
• Counselling (ACC/AHA 2020): women with mechanical heart valves considering pregnancy should be counselled that pregnancy is high risk and that no anticoagulation strategy is consistently safe for mother and baby (COR 1, LOE B-NR); women with mechanical heart valves and their providers should use shared decision-making to choose an anticoagulation strategy for pregnancy, and women should be informed that VKA during pregnancy is associated with the lowest likelihood of maternal complications but the highest likelihood of miscarriage, fetal death and congenital abnormalities, particularly if taken during the first trimester and if the warfarin dose exceeds 5 mg/d (COR 1, LOE B-NR).^[3]

ESC/EACTS 2025 reports that in a cohort of 212 women with MHVs, valve thrombosis occurred in 10 (4.7%) pregnancies and haemorrhagic events in 49 (23.1%).^[1] The full pregnancy pathway is in Heart disease in pregnancy.

Complications and pitfalls

• A DOAC for AF with a mechanical valve: not an option; ESC 2024 AF excludes mechanical heart valves from its DOAC-preference row (Class I, Level A), and ESC/EACTS 2025 says DOACs and/or DAPT are not recommended to prevent thrombosis with an MHV (Class III, Level A).^[4][1]
• A DOAC with a bioprosthesis and AF: allowed; ESC/EACTS 2025 says DOACs should be considered over VKAs after 3 months following surgical BHV implantation in AF (Class IIa, Level B).^[1]
• Rivaroxaban after TAVI without an OAC indication: ACC/AHA 2020 calls low-dose rivaroxaban plus aspirin contraindicated in that setting (COR 3: Harm, LOE B-R); ESC/EACTS 2025 says routine OAC after TAVI without a baseline indication is not recommended (Class III, Level A).^[3][1]
• Stopping warfarin for a dental extraction: in patients with an MHV, ESC/EACTS 2025 recommends continuing VKA for minor or minimally invasive interventions associated with no or minimal bleeding (Class I, Level A), and its footnote list of such interventions includes dental extractions.^[1]
• Missing mitral prosthetic thrombus on TTE: acoustic shadowing hides the left atrial side of a mitral prosthesis (ACC/AHA 2020); TOE and/or 4D-CT are recommended to confirm suspected valve thrombosis (ESC/EACTS 2025, Class I, Level C).^[2][1]
• Routine CCT for HALT: routine use of CCT to detect HALT is not indicated (ESC/EACTS 2025).^[1]
• Calling mismatch deterioration: ESC/EACTS 2025 Table 12 criteria for moderate or severe haemodynamic valve deterioration are written for SVD or non-structural valve dysfunction (except PVL or PPM), thrombosis, or endocarditis, and ESC/EACTS 2025 says a diagnosis of moderate or severe haemodynamic deterioration should prompt referral to an experienced Heart Valve Centre for evaluation and treatment, and exclusion of all causes of non-structural valve dysfunction, particularly PVL or PPM, as well as thrombosis and endocarditis.^[1]

Evidence, guidelines and regional differences

Several key decisions here rest on limited evidence.^[1][2] ESC/EACTS 2025 says most of the studies comparing long-term mortality with BHV and MHV prostheses in patients aged 50–70 years were limited by their observational nature and missing information on the type of prostheses implanted.^[1] It also says RCTs comparing the timing and dosage of each post-operative bridging strategy are lacking.^[1] ACC/AHA 2020 says there are no randomised comparative-effectiveness trials evaluating bridging versus no bridging in adequate numbers of patients with prosthetic heart valves who need temporary interruption of oral anticoagulant therapy, although it said such studies were ongoing.^[2] As dated history, the superseded 2024 AHA/ACC perioperative guideline stated that further RCTs on bridging are warranted; its full sentence is given in the dated-history section above.^[9]

^{[1] [3]}

ANZ practice

The 2024 CSANZ position statement covers transthoracic echocardiography (TTE) in structural and valvular heart disease in adults.^[8] It aims to give clinicians a framework of acceptable indications for initial and serial TTE in commonly encountered adult conditions.^[8] It also sets the minimum required standard for TTE examinations and reporting.^[8] Its abstract lists valvular heart diseases among the areas covered.^[8] Only its abstract is held for this topic, so its surveillance intervals are not quoted here. No NHFA/CSANZ guideline on prosthetic valve management was found in the guidelines checked for this topic, so the ESC/EACTS and ACC/AHA rows above apply.

Guidelines checked

A row called the newer one, or said to apply, is so among the guidelines checked for this topic:

• Sources of the rows and statements used: ESC/EACTS valvular heart disease (2025); ACC/AHA valvular heart disease (2020; rows and some supportive text from the JACC co-publication, other narrative from Circulation); ESC atrial fibrillation (2024); ACC/AHA/ACCP/HRS atrial fibrillation (2023); ESC endocarditis (2023); ESC cardiovascular disease and pregnancy (2025); the 2024 CSANZ transthoracic echocardiography position statement (abstract); and, as dated history only, the superseded 2024 AHA/ACC perioperative guideline for noncardiac surgery (text and Table 14, not its recommendation rows).^{[1][3][2][9][4][5][6][7][8]}
• Also swept for same-month or newer rows: ESC 2022 non-cardiac surgery and pulmonary hypertension; ACC/AHA 2022 aortic disease; ESC 2023 acute coronary syndromes and cardiomyopathies; AHA/ACC 2024 hypertrophic cardiomyopathy; ESC 2024 chronic coronary syndromes, hypertension and aortic diseases; ACC/AHA 2025 acute coronary syndromes; ESC 2025 myocarditis and pericarditis; ESC/EAS 2025 dyslipidaemia; AHA/ACC 2025 blood pressure; NHFA/CSANZ 2025 ACS; AHA/ACC 2026 pulmonary embolism; ACC/AHA 2026 dyslipidaemia; ESC 2026 heart failure and cardiac rehabilitation; the Fifth Universal Definition of MI.
• US perioperative guideline: the 2026 edition of the AHA/ACC multisociety guideline for perioperative cardiovascular management for noncardiac surgery (PMID 42804570, published September 2026) is not held as text for this topic, so any newer US peri-procedural rows for prosthetic valves in it could not be checked; the 2024 edition it supersedes (PMID 39316661) is held as text except its recommendation rows, which are an image in the held copy, and is quoted only as dated history.

Exam pearls

• ESC/EACTS 2025 Table 10 (first-line treatment with VKA only): 2.5 (2–3) for a bileaflet or current-generation single-tilting aortic MHV without additional pro-thrombotic factors; 3 (2.5–3.5) with them; 3 (2.5–3.5) for ball-in-cage, tilting disc or any mitral/tricuspid MHV without additional pro-thrombotic factors; 3.5 (3–4) with them. Footnote a lists the additional pro-thrombotic factors: an inherited or acquired hypercoagulable state, LV dysfunction (LVEF under 35%), AF with significant MS, and a recent (under 12 months) major thrombotic event (cardioembolic stroke, deep vein thrombosis or pulmonary embolism). Footnote b, on the 3.5 (3–4) cell: in patients at very high thrombotic risk, low-dose aspirin may be added instead. Footnote c, on the 2.5 (2–3) cell: in patients at high bleeding risk, the INR target could be maintained at a lower interval: 2 (1.5–2.5).^[1]
• No DOAC with a mechanical valve: DOACs and/or DAPT are not recommended to prevent thrombosis with an MHV (ESC/EACTS 2025, Class III, Level A); with a mechanical valve prosthesis, dabigatran is contraindicated (ACC/AHA 2020, COR 3: Harm, LOE B-R) and anti-Xa DOACs have not been assessed and are not recommended (COR 3: Harm, LOE C-EO).^[1][3]
• Major thromboembolic complication despite documented adequate INR: either an increase in INR target or the addition of low-dose aspirin 75–100 mg/day should be considered (ESC/EACTS 2025, Class IIa, Level C).^[1]
• Major non-cardiac elective surgery: it is recommended to discontinue VKA at least 4 days before, aiming for an INR under 1.5, and to resume it within 24 h after surgery, or as soon as considered safe (ESC/EACTS 2025, Class I, Level B).^[1]
• Obstructive MHV thrombosis with acute HF (NYHA class III or IV): Heart Team evaluation is recommended to determine appropriate management (repeat valve replacement or low-dose slow-infusion fibrinolysis) (ESC/EACTS 2025, Class I, Level B).^[1]
• BHV thrombosis: OAC using a VKA is recommended before considering reintervention (ESC/EACTS 2025, Class I, Level B).^[1]
• Aortic BHV, moderate haemodynamic deterioration: an increase in mean transvalvular gradient of 10 mmHg or more resulting in a mean gradient of 20 mmHg or more, and a decrease in EOA of 0.3 cm² or more or 25% or more and/or in DVI of 0.1 or more or 20% or more, compared with the echo 1–3 months post-procedure; or new occurrence or an increase of 1 grade or more of intraprosthetic AR resulting in moderate or more AR (ESC/EACTS 2025 Table 12).^[1]

References9ShowHide

1. [1]Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J, 2025.PMID 40878295
2. [2]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021.PMID 33332150
3. [3]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021.PMID 33342586
4. [4]Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2024.PMID 39210723
5. [5]Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024.PMID 38033089
6. [6]Delgado V, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J, 2023.PMID 37622656
7. [7]De Backer J, et al. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J, 2025.PMID 40878294
8. [8]Chong A, et al. 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults. Heart Lung Circ, 2024.PMID 38749800
9. [9]Thompson A, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2024.PMID 39316661