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Prosthetic heart valves

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of prosthetic heart valves are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2022,2021), the American Heart Association (AHA/ACC 2021), the European Society of Cardiology (ESC/EACTS 2021), the American College of Obstetricians and Gynecologists (ACOG 2018), the Cardiac Society of Australia and New Zealand ...
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Diagnostic investigations

Evaluation of prosthetic valve dysfunction
As per ACC/AHA 2021 guidelines:
Obtain repeat TTE in patients with a prosthetic valve and a change in clinical symptoms/signs suggesting prosthetic valve dysfunction.
B
Obtain additional imaging with TEE, gated cardiac CT, or fluoroscopy in patients with a prosthetic valve replacement and clinical symptoms/signs suggesting prosthetic valve dysfunction, even if TTE does not show valve dysfunction.
B
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  • Evaluation of prosthetic valve thrombosis

  • Evaluation of prosthetic valve stenosis

  • Evaluation of prosthetic valve regurgitation

  • Evaluation of prosthetic valve infective endocarditis (blood culture)

  • Evaluation of prosthetic valve infective endocarditis (TEE)

Medical management

Anticoagulant therapy, after surgical mechanical prosthesis implantation: as per ACC/AHA 2021 guidelines, initiate VKAs in patients with mechanical prosthetic valves.
A
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  • Anticoagulant therapy (after surgical bioprosthesis implantation)

  • Anticoagulant therapy (after TAVI)

  • Antiplatelet therapy (mechanical prostheses)

  • Antiplatelet therapy (biological prostheses)

  • Management of prosthetic valve thrombosis (mechanical prostheses, surgery)

  • Management of prosthetic valve thrombosis (mechanical prostheses, fibrinolytic therapy)

  • Management of prosthetic valve thrombosis (biological prostheses)

  • Management of prosthetic valve stenosis

  • Management of prosthetic valve regurgitation

  • Management of hemolysis and paravalvular leak

  • Management of bioprosthetic failure

  • Management of thromboembolism

  • Management of bleeding

  • Management of prosthetic valve infective endocarditis (antibiotic prophylaxis, dental procedures)

  • Management of prosthetic valve infective endocarditis (antibiotic prophylaxis, Cesarean delivery)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, acute severely ill patients)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, viridans streptococci and S. gallolyticus)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, S. pneumoniae, S. pyogenes, and beta-hemolytic streptococci)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, susceptible staphylococci)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, resistant staphylococci)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, coagulase-negative staphylococci)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, susceptible enterococci)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, resistant enterococci)

  • Management of prosthetic valve infective endocarditis (antibiotic therapy, Gram-negative bacilli)

  • Management of prosthetic valve infective endocarditis (antifungal therapy)

  • Management of prosthetic valve infective endocarditis (management of antithrombotics)

  • Management of prosthetic valve infective endocarditis (device removal)

  • Management of prosthetic valve infective endocarditis (indications for surgery)

Perioperative care

Peri-implantation antibiotic prophylaxis
As per ESC 2021 guidelines:
Eliminate potential sources of sepsis ≥ 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, except in urgent procedures.
B
Consider administering perioperative antibiotic prophylaxis in patients undergoing surgical or transcatheter implantation of a prosthetic valve, intravascular prosthetic, or other foreign material.
C

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  • Peri-implantation anticoagulant therapy (discontinuation)

  • Peri-implantation anticoagulant therapy (bridging)

  • Peri-implantation anticoagulant therapy (reinitiation)

  • Peri-implantation antiplatelet therapy

  • Post-implantation imaging

  • Perioperative management of anticoagulants (discontinuation)

  • Perioperative management of anticoagulants (reversal)

  • Perioperative management of anticoagulants (bridging)

Surgical interventions

Choice of prosthetic valve, general principles
As per ACC/AHA 2021 guidelines:
Decide on the choice of prosthetic valve in patients requiring heart valve replacement based on a shared decision-making process, taking into account the patient's values and preferences, including a discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.
B
Consider individualizing the choice between mechanical and bioprosthetic aortic valve replacement in 50-65 years old patients requiring aortic valve replacement and not having contraindications to anticoagulation, taking into account individual patient factors and after informed shared decision-making.
C

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  • Choice of prosthetic valve (mechanical prostheses)

  • Choice of prosthetic valve (biological prostheses)

Specific circumstances

Pediatric patients: as per ACCP 2012 guidelines, manage pediatric patients with biologic or mechanical prosthetic heart valves according to relevant recommendations for the adult population.

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  • Pregnant patients

Follow-up and surveillance

Surveillance imaging
As per ACC/AHA 2021 guidelines:
Consider obtaining TTEs at 5 and 10 years and then annually after implantation in patients with a bioprosthetic surgical valve, even without a change in clinical status.
C
Consider obtaining annual TTEs in patients with a bioprosthetic TAVI.
C