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Complications of prosthetic heart valves

William H Gaasch, MD
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Replacement of a diseased heart valve with a prosthetic heart valve exchanges the native disease for prosthesis-related complications [1-3]. The incidence of serious complications in appropriately managed patients with prosthetic heart valves is approximately 3 percent per year. The frequency of various complications depends upon the valve type (mechanical versus bioprosthetic) and position, and multiple clinical risk factors, including adequacy of anticoagulation and the patient’s life expectancy. Complications include embolic events, bleeding, prosthetic heart valve obstruction or stenosis, prosthetic heart valve regurgitation (valvular and paravalvular), infective endocarditis, hemolytic anemia, and patient-prosthesis mismatch.

Prosthetic valve complications are reviewed here. Issues related to the monitoring and antithrombotic therapy in patients (including pregnant women) with prosthetic valves, bleeding complications, choice of prosthetic valve, transcatheter aortic valve replacement complications, and patient-prosthesis mismatch are discussed separately. (See "Overview of the management of patients with prosthetic heart valves" and "Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures" and "Antithrombotic therapy for prosthetic heart valves: Indications" and "Management of pregnant women with prosthetic heart valves" and "Surgical procedures for severe chronic mitral regurgitation" and "Transcatheter aortic valve replacement: Overview of complications" and "Choice of prosthetic heart valve for surgical replacement", section on 'Prosthetic valve-patient mismatch'.)


Thrombus forming on a prosthetic valve can be non-obstructive or obstructive, can cause clinical thromboembolic events, can occur on mechanical or bioprosthetic valves, and can occur early or late after valve surgery [4-7].

Terminology — The two complications resulting from thrombus forming on a prosthetic valve are thromboembolism and prosthetic valve thrombosis (PVT). While these complications both result from thrombus forming on a valve, clinical manifestations of thromboembolism or valve thrombosis are distinct and may occur separately or concurrently.

The term “thromboembolism” is commonly used to indicate clinical embolic events ascribed to thrombus.  


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Literature review current through: Sep 2016. | This topic last updated: Feb 29, 2016.
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  1. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
  2. Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
  3. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  4. Hammermeister KE, Sethi GK, Henderson WG, et al. A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease. N Engl J Med 1993; 328:1289.
  5. Hammermeister K, Sethi GK, Henderson WG, et al. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000; 36:1152.
  6. Dürrleman N, Pellerin M, Bouchard D, et al. Prosthetic valve thrombosis: twenty-year experience at the Montreal Heart Institute. J Thorac Cardiovasc Surg 2004; 127:1388.
  7. Roudaut R, Serri K, Lafitte S. Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations. Heart 2007; 93:137.
  8. Le Tourneau T, Lim V, Inamo J, et al. Achieved anticoagulation vs prosthesis selection for mitral mechanical valve replacement: a population-based outcome study. Chest 2009; 136:1503.
  9. Heras M, Chesebro JH, Fuster V, et al. High risk of thromboemboli early after bioprosthetic cardiac valve replacement. J Am Coll Cardiol 1995; 25:1111.
  10. Cannegieter SC, Rosendaal FR, Wintzen AR, et al. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med 1995; 333:11.
  11. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 1994; 89:635.
  12. Bloomfield P, Wheatley DJ, Prescott RJ, Miller HC. Twelve-year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. N Engl J Med 1991; 324:573.
  13. Oxenham H, Bloomfield P, Wheatley DJ, et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 2003; 89:715.
  14. Stassano P, Di Tommaso L, Monaco M, et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009; 54:1862.
  15. Kulik A, Bédard P, Lam BK, et al. Mechanical versus bioprosthetic valve replacement in middle-aged patients. Eur J Cardiothorac Surg 2006; 30:485.
  16. Ozkan M, Gürsoy OM, Astarcıoğlu MA, et al. Real-time three-dimensional transesophageal echocardiography in the assessment of mechanical prosthetic mitral valve ring thrombosis. Am J Cardiol 2013; 112:977.
  17. Barbetseas J, Pitsavos C, Aggeli C, et al. Comparison of frequency of left atrial thrombus in patients with mechanical prosthetic cardiac valves and stroke versus transient ischemic attacks. Am J Cardiol 1997; 80:526.
  18. Puvimanasinghe JP, Steyerberg EW, Takkenberg JJ, et al. Prognosis after aortic valve replacement with a bioprosthesis: predictions based on meta-analysis and microsimulation. Circulation 2001; 103:1535.
  19. Remadi JP, Baron O, Roussel C, et al. Isolated mitral valve replacement with St. Jude medical prosthesis: long-term results: a follow-up of 19 years. Circulation 2001; 103:1542.
  20. Deviri E, Sareli P, Wisenbaugh T, Cronje SL. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management. J Am Coll Cardiol 1991; 17:646.
  21. Laplace G, Lafitte S, Labèque JN, et al. Clinical significance of early thrombosis after prosthetic mitral valve replacement: a postoperative monocentric study of 680 patients. J Am Coll Cardiol 2004; 43:1283.
  22. Egbe AC, Pislaru SV, Pellikka PA, et al. Bioprosthetic Valve Thrombosis Versus Structural Failure: Clinical and Echocardiographic Predictors. J Am Coll Cardiol 2015; 66:2285.
  23. Cremer PC, Rodriguez LL, Griffin BP, et al. Early Bioprosthetic Valve Failure: Mechanistic Insights via Correlation between Echocardiographic and Operative Findings. J Am Soc Echocardiogr 2015; 28:1131.
  24. Pislaru SV, Hussain I, Pellikka PA, et al. Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series. Eur J Cardiothorac Surg 2015; 47:725.
  25. Burke AP, Farb A, Sessums L, Virmani R. Causes of sudden cardiac death in patients with replacement valves: an autopsy study. J Heart Valve Dis 1994; 3:10.
  26. Ueda T, Teshima H, Fukunaga S, et al. Evaluation of prosthetic valve obstruction on electrocardiographically gated multidetector-row computed tomography--identification of subprosthetic pannus in the aortic position. Circ J 2013; 77:418.
  27. Suchá D, Symersky P, Tanis W, et al. Multimodality Imaging Assessment of Prosthetic Heart Valves. Circ Cardiovasc Imaging 2015; 8:e003703.
  28. Habets J, Symersky P, van Herwerden LA, et al. Prosthetic heart valve assessment with multidetector-row CT: imaging characteristics of 91 valves in 83 patients. Eur Radiol 2011; 21:1390.
  29. Gündüz S, Özkan M, Kalçik M, et al. Sixty-Four-Section Cardiac Computed Tomography in Mechanical Prosthetic Heart Valve Dysfunction: Thrombus or Pannus. Circ Cardiovasc Imaging 2015; 8.
  30. Biteker M, Altun I, Basaran O, et al. Treatment of Prosthetic Valve Thrombosis: Current Evidence and Future Directions. J Clin Med Res 2015; 7:932.
  31. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  32. Salem DN, O'Gara PT, Madias C, et al. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:593S.
  33. Alpert JS. The thrombosed prosthetic valve: current recommendations based on evidence from the literature. J Am Coll Cardiol 2003; 41:659.
  34. Roudaut R, Lafitte S, Roudaut MF, et al. Fibrinolysis of mechanical prosthetic valve thrombosis: a single-center study of 127 cases. J Am Coll Cardiol 2003; 41:653.
  35. Karthikeyan G, Senguttuvan NB, Joseph J, et al. Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies. Eur Heart J 2013; 34:1557.
  36. Huang G, Schaff HV, Sundt TM, Rahimtoola SH. Treatment of obstructive thrombosed prosthetic heart valve. J Am Coll Cardiol 2013; 62:1731.
  37. Tong AT, Roudaut R, Ozkan M, et al. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry. J Am Coll Cardiol 2004; 43:77.
  38. Özkan M, Gündüz S, Gürsoy OM, et al. Ultraslow thrombolytic therapy: A novel strategy in the management of PROsthetic MEchanical valve Thrombosis and the prEdictors of outcomE: The Ultra-slow PROMETEE trial. Am Heart J 2015; 170:409.
  39. Gueret P, Vignon P, Fournier P, et al. Transesophageal echocardiography for the diagnosis and management of nonobstructive thrombosis of mechanical mitral valve prosthesis. Circulation 1995; 91:103.
  40. Bemurat LR, Laffort PR, Deville CJ, et al. Management of Nonobstructive Thrombosis of Prosthetic Mitral Valve in Asymptomatic Patients in the Early Postoperative Period: A Study in 20 Patients. Echocardiography 1999; 16:339.
  41. Taherkhani M, Hashemi SR, Hekmat M, et al. Thrombolytic Therapy for Right-Sided Mechanical Pulmonic and Tricuspid Valves: The Largest Survival Analysis to Date. Tex Heart Inst J 2015; 42:543.
  42. Butnaru A, Shaheen J, Tzivoni D, et al. Diagnosis and treatment of early bioprosthetic malfunction in the mitral valve position due to thrombus formation. Am J Cardiol 2013; 112:1439.
  43. Jander N, Kienzle RP, Kayser G, et al. Usefulness of phenprocoumon for the treatment of obstructing thrombus in bioprostheses in the aortic valve position. Am J Cardiol 2012; 109:257.
  44. van Gorp MJ, Steyerberg EW, Van der Graaf Y. Decision guidelines for prophylactic replacement of Björk-Shiley convexo-concave heart valves: impact on clinical practice. Circulation 2004; 109:2092.
  45. Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med 1996; 335:407.
  46. Yacoub M, Rasmi NR, Sundt TM, et al. Fourteen-year experience with homovital homografts for aortic valve replacement. J Thorac Cardiovasc Surg 1995; 110:186.
  47. O'Brien MF, Stafford EG, Gardner MA, et al. Allograft aortic valve replacement: long-term follow-up. Ann Thorac Surg 1995; 60:S65.
  48. Glower DD, Landolfo KP, Cheruvu S, et al. Determinants of 15-year outcome with 1,119 standard Carpentier-Edwards porcine valves. Ann Thorac Surg 1998; 66:S44.
  49. Poirer NC, Pelletier LC, Pellerin M, Carrier M. 15-year experience with the Carpentier-Edwards pericardial bioprosthesis. Ann Thorac Surg 1998; 66:S57.
  50. Yun KL, Miller DC, Moore KA, et al. Durability of the Hancock MO bioprosthesis compared with standard aortic valve bioprostheses. Ann Thorac Surg 1995; 60:S221.
  51. Rahimtoola SH. Choice of prosthetic heart valve for adult patients. J Am Coll Cardiol 2003; 41:893.
  52. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 2009; 22:975.
  53. Barbetseas J, Nagueh SF, Pitsavos C, et al. Differentiating thrombus from pannus formation in obstructed mechanical prosthetic valves: an evaluation of clinical, transthoracic and transesophageal echocardiographic parameters. J Am Coll Cardiol 1998; 32:1410.
  54. Lin SS, Tiong IY, Asher CR, et al. Prediction of thrombus-related mechanical prosthetic valve dysfunction using transesophageal echocardiography. Am J Cardiol 2000; 86:1097.
  55. Tanis W, Habets J, van den Brink RB, et al. Differentiation of thrombus from pannus as the cause of acquired mechanical prosthetic heart valve obstruction by non-invasive imaging: a review of the literature. Eur Heart J Cardiovasc Imaging 2014; 15:119.
  56. Rallidis LS, Moyssakis IE, Ikonomidis I, Nihoyannopoulos P. Natural history of early aortic paraprosthetic regurgitation: a five-year follow-up. Am Heart J 1999; 138:351.
  57. O'Rourke DJ, Palac RT, Malenka DJ, et al. Outcome of mild periprosthetic regurgitation detected by intraoperative transesophageal echocardiography. J Am Coll Cardiol 2001; 38:163.
  58. Alam M, Serwin JB, Rosman HS, et al. Transesophageal echocardiographic features of normal and dysfunctioning bioprosthetic valves. Am Heart J 1991; 121:1149.
  59. Reed GW, Tuzcu EM, Kapadia SR, Krishnaswamy A. Catheter-based closure of paravalvular leak. Expert Rev Cardiovasc Ther 2014; 12:681.
  60. Skoularigis J, Essop MR, Skudicky D, et al. Frequency and severity of intravascular hemolysis after left-sided cardiac valve replacement with Medtronic Hall and St. Jude Medical prostheses, and influence of prosthetic type, position, size and number. Am J Cardiol 1993; 71:587.
  61. Shapira Y, Vaturi M, Sagie A. Hemolysis associated with prosthetic heart valves: a review. Cardiol Rev 2009; 17:121.
  62. Kloster FE. Diagnosis and management of complications of prosthetic heart valves. Am J Cardiol 1975; 35:872.
  63. Ismeno G, Renzulli A, Carozza A, et al. Intravascular hemolysis after mitral and aortic valve replacement with different types of mechanical prostheses. Int J Cardiol 1999; 69:179.
  64. Enzenauer RJ, Berenberg JL, Cassell PF Jr. Microangiopathic hemolytic anemia as the initial manifestation of porcine valve failure. South Med J 1990; 83:912.
  65. Maraj R, Jacobs LE, Ioli A, Kotler MN. Evaluation of hemolysis in patients with prosthetic heart valves. Clin Cardiol 1998; 21:387.
  66. Hirawat S, Lichtman SM, Allen SL. Recombinant human erythropoietin use in hemolytic anemia due to prosthetic heart valves: a promising treatment. Am J Hematol 2001; 66:224.