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cardio.prosthetic-valve.management.v1

Prosthetic heart valve — chronic management

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Prosthetic valve chronic management — antithrombotic strategy by valve type/position + complication set (thrombosis/SVD/PVE/paravalvular leak/bridging/valve-in-valve). Hard rules: mechanical = lifelong VKA, DOAC contraindicated (RE-ALIGN); bioprosthetic/TAVR = single antiplatelet (POPULAR-TAVI); bioprosthetic+AF DOAC after 3 mo (RIVER). Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (antithrombotic + complication axis + workups + calculators + panels), test_files, 9-PMID evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): warfarin/aspirin/apixaban/rivaroxaban/enoxaparin RxCUIs reused from validated cardio dossiers; procedure entries (fibrinolysis, valve-in-valve, PVL closure, bridging) marked non_pharm. 9 trigger/special-pop branches: obstructive thrombosis, DOAC-on-mechanical, pregnancy-with-mechanical-valve, peri-procedural bridging, SVD, PVE, paravalvular leak, bioprosthetic+AF, CKD.

Entry points (5)

  • problem_list
    Mechanical / bioprosthetic / TAVR valve — surveillance visit
    prosthetic_valve_present
  • lab_abnormality
    Sub-/supra-therapeutic INR on mechanical-valve VKA
    subtherapeutic_inr
  • symptom
    New prosthetic murmur / dyspnea / heart failure
    new_prosthetic_murmur_or_dyspnea
  • history
    Upcoming surgery/procedure — bridging decision
    pre_procedure_bridging_query
  • lab_abnormality
    Hemolysis (↑LDH, ↓haptoglobin, schistocytes) — paravalvular leak query
    hemolysis_labs

Required inputs (11)

  • agerequired
    demographic • used at RISK_STRATIFICATION
    Valve-choice + bleeding risk + reoperation risk
  • valve_typerequired
    history • used at FRAME
    Mechanical vs bioprosthetic vs TAVR — determines the entire antithrombotic strategy
  • valve_positionrequired
    history • used at FRAME
    Aortic vs mitral vs tricuspid — INR target + thrombogenicity differ
  • implant_daterequired
    history • used at CONTEXT
    First 3–6 mo bioprosthetic AC window; SVD timeline
  • inrrequired
    lab • used at TREATMENT
    VKA control / TTR for mechanical valves; target band by valve
  • atrial_fibrillation
    history • used at CONTEXT
    AF changes bioprosthetic AC (DOAC ok after 3 mo) — never mechanical
  • bleeding_risk
    history • used at RISK_STRATIFICATION
    Aspirin add-on + INR target individualisation
  • prosthesis_gradients
    imaging • used at INITIAL_WORKUP
    Elevated gradients → thrombosis/pannus/SVD/PPM differential
  • hemolysis_panel
    lab • used at INITIAL_WORKUP
    LDH/haptoglobin/schistocytes — paravalvular leak detection
  • pregnancy_status
    demographic • used at CONTEXT
    Mechanical valve + pregnancy = warfarin-vs-LMWH dilemma (mWHO III–IV)
  • creatininerequired
    lab • used at TREATMENT
    LMWH/DOAC renal dosing; mechanical still VKA regardless

12-phase flow (12)

  1. 1FRAME
    Establish valve type + position + implant date — drives antithrombotic strategy
    inputs: valve_type, valve_position
    advance: valve identity established
  2. 2ENTRY
    Surveillance, INR management, new symptom, pre-procedure, hemolysis
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Valve details, AC regimen + control, bleeding/thrombotic risk, AF, pregnancy
    inputs: implant_date, atrial_fibrillation, pregnancy_status
    advance: AC + risk context complete
  4. 4RED_FLAGS
    Obstructive valve thrombosis, PVE, acute severe paravalvular regurgitation, major bleed
    inputs: prosthesis_gradients
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to emergency pathway
  5. 5INITIAL_WORKUP
    TTE (gradients, regurgitation, function), INR, hemolysis labs, ECG
    inputs: inr, prosthesis_gradients, hemolysis_panel
    actions: panel.cardiac, panel.cbc
    advance: prosthesis function + AC status quantified
  6. 6BRANCHING_WORKUP
    TEE/fluoroscopy/CT for thrombosis vs pannus; blood cultures for PVE; quantify paravalvular leak
    inputs: prosthesis_gradients
    actions: preop_cardiac, afib_new_onset
    advance: complication mechanism identified
  7. 7DIFFERENTIAL
    SVD vs thrombosis vs pannus vs PVE vs paravalvular leak vs patient-prosthesis mismatch
    inputs: prosthesis_gradients
    advance: complication differential resolved
  8. 8RISK_STRATIFICATION
    Thromboembolic vs bleeding risk; reoperation risk; INR target band
    inputs: age, bleeding_risk
    advance: risk + INR target assigned
  9. 9TREATMENT
    Antithrombotic by valve/position; bridging; thrombosis (lysis vs surgery); SVD → valve-in-valve; PVE → IE engine
    inputs: valve_type, inr, creatinine
    advance: antithrombotic + complication plan documented
  10. 10DISPOSITION
    Valve clinic cadence; structural-heart/surgery referral on complication
    inputs: valve_type
    actions: preop_cardiac
    advance: follow-up / referral plan set
  11. 11MONITORING
    INR cadence/TTR, surveillance echo, hemolysis labs
    inputs: inr
    actions: panel.cardiac, panel.renal
    advance: monitoring cadence documented
  12. 12FOLLOWUP
    Lifelong; pregnancy + procedure planning; SVD watch for bioprosthesis
    inputs: valve_type
    advance: lifelong plan + escalation triggers documented