Prosthetic Valves

• All prosthetic heart valves have an expected amount of stenosis.
• Prosthetic valves are designed to have a small amount of regurgitation, i.e. “physiological closing volume.”

Which valve should they get?

Management

• Asymptomatic patients can generally be followed with a clinician examination annually.

Anticoagulation

• In patients with a mechanical prosthetic valve, anticoagulation with warfarin is recommended (Class 1)
• Bioprosthetic valves
  • TAVI:
    • if low risk of bleeding, DAPT with aspirin 75 to 100 mg daily + clopidogrel 75 mg daily for 3-6 months post-implantation (Class 2a)
    • aspirin 75 to 100 mg daily is reasonable (Class 2a)
  • Bioprosthetic SAVR:
    • if low risk of bleeding, warfarin (Goal INR 2.5) for 3-6 months after surgery (Class 2a)
    • aspirin 75 to 100 mg daily is reasonable (Class 2a)

Endocarditis Prophylaxis

Echo Surveillance

• Initial Echo
  • “In patients with a surgical or transcatheter prosthetic valve and in patients who have had valve repair, an initial postprocedural TTE study is recommended for evaluation of valve hemodynamics and ventricular function” (Class 1)
• Surveillance Echo
  • Guidelines recommend a follow-up echocardiogram 4-12 weeks after valve surgery to establish a new baseline.
    • Waiting several weeks allows for recovery of anemia, stabilization from any early postoperative fluid shifts, and stabilization from perioperative medications, which may alter valvular gradients and/or ventricular mechanics early on.
  • Bioprosthetic valves
    • In patients with a bioprosthetic surgical valve, TTE at 5 and 10 years and then annually after implantation is reasonable, even in the absence of a change in clinical status. (Class 2a)
    • In patients with a bioprosthetic TAVI, TTE annually is reasonable (Class 2a)
• Clinical deterioration → get a TTE (Class 1)
  • If TTE doesn’t show valve dysfunction, get additional imaging (TEE, gated cardiac CT, or fluoro) (Class 1)

Bioprosthetic Valves

• Surveillance Echo