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Subclinical Bioprosthetic Valve Thrombosis — EECC MCQ

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ModerateValvular Heart DiseaseSubclinical Bioprosthetic Valve ThrombosisEECC

A 62-year-old man with a bioprosthetic mitral valve presents with gradual onset of dyspnoea. Echocardiography shows increased mean gradient across the prosthesis (12 mmHg, previously 5 mmHg) with restricted leaflet motion. CT shows thickening of the valve leaflets with hypoattenuating material. What is the most likely diagnosis?

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Correct answer: E — Subclinical bioprosthetic valve thrombosis (BPVT) — hypoattenuating leaflet thickening on CT represents thrombus on the prosthetic leaflets causing restricted motion and elevated gradients; a trial of anticoagulation (warfarin or DOAC) may resolve the thrombus

Subclinical bioprosthetic valve thrombosis (BPVT) has become increasingly recognised since the widespread use of CT in valve assessment: (1) hypoattenuating leaflet thickening (HALT) and reduced leaflet motion (RLM) on 4D cardiac CT represent thrombus deposition on prosthetic valve leaflets; (2) prevalence: 10-15% of surgical bioprostheses and ~13-40% of TAVI valves (higher incidence in TAVI may be related to suboptimal haemodynamics); (3) clinical significance: may cause elevated gradients, restrict leaflet motion, and potentially increase thromboembolic risk; (4) treatment: therapeutic anticoagulation (warfarin or DOAC) often resolves the thrombus (HALT reversal demonstrated on repeat CT). The 2025 ESC VHD Guidelines acknowledge BPVT as an emerging entity; routine CT surveillance of all bioprostheses is NOT recommended, but CT should be considered for: unexplained gradient elevation, TIA/stroke with bioprosthesis, and research protocols.

Reference: ESC/EACTS (2025): VHD Guidelines