Bioprosthetic Valve Dysfunction - Thrombosis vs SVD — EECC MCQ

Correct answer: B — Trial of therapeutic anticoagulation intensification (target INR 3.0-4.0) for 1-3 months, with repeat imaging to assess for leaflet mobility improvement

The echo findings are most consistent with bioprosthetic mitral valve thrombosis: new breathlessness, thickened immobile prosthetic leaflets, and a marked rise in mean transmitral gradient from 4 to 12 mmHg without regurgitation. In current practice, suspected/confirmed biological heart valve thrombosis should be treated with oral anticoagulation using a vitamin K antagonist before considering reintervention; reduced leaflet motion with elevated gradients is treated until resolution and reassessed with repeat imaging. As he is already anticoagulated but remains obstructed, the appropriate first step is specialist-led intensification of warfarin anticoagulation, targeting INR 3.0-4.0 for 1-3 months, followed by repeat echocardiography/TOE or CT to look for improved leaflet mobility and reduced gradient. Immediate redo surgery or valve-in-valve intervention is reserved for failure of anticoagulation, haemodynamic instability, or non-thrombotic structural valve degeneration. Adding aspirin is not the primary treatment for valve thrombosis and increases bleeding risk; reducing warfarin is unsafe because the gradient rise is clinically significant; transplantation is inappropriate.

Reference: 2025 ESC/EACTS Guidelines for the management of valvular heart disease, Recommendation Table 17: OAC using VKA is recommended in biological heart valve thrombosis before considering reintervention; OAC should be considered for leaflet thickening/reduced motion causing elevated gradients until resolution. https://www.eacts.org/clinical-practice-guideline/2025-esc-eacts-guidelines-for-the-management-of-valvular-heart-disease-developed-by-the-task-force-for-the-management-of-valvular-heart-disease-of-the-european-society-of-cardiology-esc-and-the-eur/