What is the importance of real-time three dimensional transesophageal echocardiography and time in therapeutic range in patients with prosthetic valve thrombosis?

Diagnosis of Left-Sided Mechanical Prosthetic Valve Thrombosis: A Pictorial Review

Although transcatheter valve therapy is rapidly evolving, surgical valve replacement is still required in many patients with severe left-side valve stenosis or regurgitation, the mechanical bi-leaflet heart valve being the standard prosthesis type in younger patients. Moreover, the prevalence of valvular heart disease is steadily increasing, especially in industrialized countries, and the problem of lifelong efficient anticoagulation of these patients remains fundamental, especially in the context where vitamin K antagonists continue to be the current standard of anticoagulation despite a level of oscillating anticoagulation. In this setting, avoiding prosthetic valve thrombosis after surgery is the number one objective for both the patient and the responsible physicians. Although rare, this complication is life threatening, with the sudden onset of acute cardiac failure such as acute pulmonary edema, cardiogenic shock, or sudden cardiac death and inadequate anticoagulation remaining the leading cause of prosthesis thrombosis, along with other risk factors. The availability of multimodal imaging techniques enables and encompasses to a full extent the diagnosis of mechanical valve thrombosis. The gold-standard diagnostic methods are transthoracic and transesophageal echocardiography. Moreover, 3D ultrasound has undoubted value in giving a more accurate description of the thrombus's extension. When transthoracic and transesophageal echocardiography are uncertain, the multidetector computer tomography examination is an important complementary imaging method. Fluoroscopy is also an excellent tool for evaluating the mobility of prosthetic discs. Each method complements the other to differentiate an acute mechanical valve thrombosis from other prosthetic valve pathologies such as pannus formation or infective endocarditis and aids the physician in accurately establishing the treatment method (surgical or pharmaceutical) and its optimal timing. The aim of this pictorial review was to discuss from an imagistic perspective the mechanical prosthetic aortic and mitral valve thrombosis and to provide an overview of the essential role of non-invasive exploration in the treatment of this severe complication.

Editorial commentary: Cutting the Gordian knot of right-sided prosthetic valve thrombosis

With limited data available for the tricuspid valve, there are no stringent recommendations in the current guidelines (ESC 2021). Valve replacement for the right-sided heart is inherently problematic and bears the potential for complications - including prosthetic valve thrombosis (PVT). The purpose of this editorial is to review the key features of this clinical scenario and to outline the essential aspects for optimized patient management and improved outcome. Depending on the clinical presentation of PVT, either immediate surgery, thrombolysis, or anticoagulation may be considered - with the sole intensification of anticoagulation likely being the most inferior. Given the high risk of re-thrombosis, a dedicated follow-up program is essential to identify complications early and offer adequate treatment.