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cardio.prosthetic-valve.management.v1PRODUCTION
cardio.prosthetic-valve.management.v1

Prosthetic heart valve — chronic management

cardiologychronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Establish valve type + position + implant date — drives antithrombotic strategy

Inputs
2
Actions
0
Advance rule
Set
Advance when

valve identity established

Patient inputs (11)

First 3–6 mo bioprosthetic AC window; SVD timeline

Mechanical vs bioprosthetic vs TAVR — determines the entire antithrombotic strategy

Aortic vs mitral vs tricuspid — INR target + thrombogenicity differ

Valve-choice + bleeding risk + reoperation risk

VKA control / TTR for mechanical valves; target band by valve

LMWH/DOAC renal dosing; mechanical still VKA regardless

AF changes bioprosthetic AC (DOAC ok after 3 mo) — never mechanical

Mechanical valve + pregnancy = warfarin-vs-LMWH dilemma (mWHO III–IV)

Elevated gradients → thrombosis/pannus/SVD/PPM differential

LDH/haptoglobin/schistocytes — paravalvular leak detection

Aspirin add-on + INR target individualisation

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningobstructive_prosthetic_thrombosis
    Obstructive prosthetic valve thrombosis (high gradients, reduced leaflet motion, HF/shock) — EMERGENCY: fibrinolysis vs surgery — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningprosthetic_valve_endocarditis
    Fever/bacteremia/new regurgitation with a prosthesis — prosthetic valve endocarditis: route to IE engine, early-surgery indications — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredoac_on_mechanical_valve
    DOAC prescribed for a mechanical valve — switch to VKA immediately (RE-ALIGN: excess thromboembolism + bleeding) — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_mechanical_valve
    Pregnancy with a mechanical valve — warfarin most effective but teratogenic 1st trimester; LMWH (anti-Xa guided) alternative; mWHO III–IV; multidisciplinary — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestructural_valve_deterioration
    Bioprosthetic SVD (rising gradient / new regurgitation, typically >5–10 yr) — valve-in-valve TAVR or redo surgery — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparavalvular_leak_hemolysis
    Paravalvular leak with hemolytic anemia or HF — percutaneous closure or reoperation — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateperi_procedural_bridging
    Upcoming surgery/procedure with a mechanical valve — bridging plan (mechanical MVR / older valve / risk factors = bridge; bileaflet mechanical AVR low-risk minor procedure may not) — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebioprosthetic_af_anticoagulation
    Bioprosthetic valve + AF >3 mo post-implant — DOAC acceptable (apixaban; rivaroxaban for bioprosthetic mitral per RIVER) — NEVER for mechanical — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — LMWH/DOAC renal dose-gating; mechanical valves remain on VKA regardless of renal function — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

Prosthetic valve antithrombotic + complication management (2020 ACC/AHA VHD; 2021 ESC/EACTS VHD)
axis: prosthetic_valve_antithromboticstep 1 - Step 1 — Mechanical valve: lifelong VKA (DOAC CONTRAINDICATED)
Selected step "Step 1 — Mechanical valve: lifelong VKA (DOAC CONTRAINDICATED)" — Any mechanical prosthesis
  • warfarin
    first line
    VKA
    INR-guided • PO • once daily (max: titrate to INR target)
    triggers: mechanical_AVR_INR_2.5, mechanical_AVR_with_risk_INR_3.0, mechanical_MVR_INR_3.0
    Mechanical AVR bileaflet no risk → INR 2.5 (2.0–3.0); AVR with risk / older valve → 3.0; mechanical MVR → 3.0 (2.5–3.5). RE-ALIGN: dabigatran caused excess thromboembolism + bleeding — DOAC contraindicated (2020 ACC/AHA VHD)
    rxcui 855296
  • aspirin
    add on
    antiplatelet
    75–100 mg • PO • once daily
    triggers: low_bleeding_risk_mechanical_valve
    Low-dose aspirin add-on reasonable with VKA if low bleeding risk (2020 ACC/AHA VHD)
    rxcui 1191

outpatient playbook — drug actions (2)

  1. 1. warfarin (mechanical) to valve-specific INR
    INR 2.5 AVR / 3.0 MVR or high-risk • PO • daily
    trigger: Mechanical valve (2020 ACC/AHA VHD)
    Lifelong VKA; DOAC contraindicated (RE-ALIGN)
  2. 2. aspirin (bioprosthetic/TAVR after window)
    75–100 mg • PO • daily
    trigger: Bioprosthetic/TAVR (2020 ACC/AHA VHD)
    POPULAR-TAVI — single antiplatelet

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Mechanical / bioprosthetic / TAVR valve — surveillance visit; Sub-/supra-therapeutic INR on mechanical-valve VKA; New prosthetic murmur / dyspnea / heart failure.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Prosthetic heart valve — chronic management** (cardio.prosthetic-valve.management.v1).
Phenotype framing: SVD vs thrombosis vs pannus vs PVE vs paravalvular leak vs patient-prosthesis mismatch
Scope: Establish valve type + position + implant date — drives antithrombotic strategy

No severity triggers fired against current inputs.

Plan

Regimen axis: **Prosthetic valve antithrombotic + complication management (2020 ACC/AHA VHD; 2021 ESC/EACTS VHD)** — step "Step 1 — Mechanical valve: lifelong VKA (DOAC CONTRAINDICATED)".
1. warfarin INR-guided PO once daily (VKA, first line) — Mechanical AVR bileaflet no risk → INR 2.5 (2.0–3.0); AVR with risk / older valve → 3.0; mechanical MVR → 3.0 (2.5–3.5). RE-ALIGN: dabigatran caused excess thromboembolism + bleeding — DOAC contraindicated (2020 ACC/AHA VHD)
2. aspirin 75–100 mg PO once daily (antiplatelet, add on) — Low-dose aspirin add-on reasonable with VKA if low bleeding risk (2020 ACC/AHA VHD)

Setting playbook (outpatient) — Maintain valve-appropriate antithrombotic therapy, surveil for complications, plan procedures/pregnancy (2020 ACC/AHA VHD)
3. warfarin (mechanical) to valve-specific INR INR 2.5 AVR / 3.0 MVR or high-risk PO daily — Mechanical valve (2020 ACC/AHA VHD) (Lifelong VKA; DOAC contraindicated (RE-ALIGN))
4. aspirin (bioprosthetic/TAVR after window) 75–100 mg PO daily — Bioprosthetic/TAVR (2020 ACC/AHA VHD) (POPULAR-TAVI — single antiplatelet)

Non-pharmacologic actions:
- Endocarditis prophylaxis education (prosthetic material = high-risk) — 2020 ACC/AHA VHD
- Procedure-bridging plan for mechanical valves — 2020 ACC/AHA VHD
- Pregnancy pre-conception counseling for women with mechanical valves — ESC 2018 Pregnancy

AVOID / contraindication checks:
- DOAC absolutely contraindicated mechanical valves — RE ALIGN Eikelboom NEJM 2013
- DOAC contraindicated rheumatic MS regardless of prosthesis — 2020 ACC/AHA VHD
- Never interrupt mechanical valve AC without a bridging plan — 2020 ACC/AHA VHD
- Warfarin teratogenic 1st trimester shared decision with LMWH in pregnancy — ESC 2018 Pregnancy
- Obstructive prosthetic thrombosis is an emergency not outpatient — 2020 ACC/AHA VHD

Monitoring

Regimen monitoring:
- INR cadence and TTR for mechanical valves — 2020 ACC/AHA VHD
- surveillance TTE baseline then annually and with symptom change — 2020 ACC/AHA VHD
- hemolysis panel LDH haptoglobin if paravalvular leak suspected — 2020 ACC/AHA VHD
- anti-Xa monitoring if LMWH in pregnancy — ESC 2018 Pregnancy
- SVD surveillance echo for bioprosthesis beyond 5-10y — 2020 ACC/AHA VHD

Setting (outpatient) monitoring:
- INR cadence/TTR; annual surveillance TTE — 2020 ACC/AHA VHD
- Hemolysis labs as indicated — 2020 ACC/AHA VHD

Follow-up plan: Lifelong; pregnancy + procedure planning; SVD watch for bioprosthesis
- Close-out criterion: lifelong plan + escalation triggers documented

Monitoring phase: INR cadence/TTR, surveillance echo, hemolysis labs

Disposition

Current setting: outpatient — Maintain valve-appropriate antithrombotic therapy, surveil for complications, plan procedures/pregnancy (2020 ACC/AHA VHD)

Disposition criteria:
- Stable, therapeutic AC, normal prosthesis → annual valve clinic
- Complication → structural-heart / cardiac-surgery referral

Escalation triggers (move to higher acuity):
- Obstructive valve thrombosis / acute prosthetic dysfunction → ED emergency — 2020 ACC/AHA VHD
- New regurgitation + hemolysis/HF → paravalvular-leak intervention — 2020 ACC/AHA VHD
- Fever/bacteremia + prosthesis → PVE workup, route to IE engine — 2020 ACC/AHA VHD

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Obstructive prosthetic valve thrombosis (high gradients, reduced leaflet motion, HF/shock) — EMERGENCY: fibrinolysis vs surgery — 2020 ACC/AHA VHD
- [LIFE_THREATENING] Fever/bacteremia/new regurgitation with a prosthesis — prosthetic valve endocarditis: route to IE engine, early-surgery indications — 2020 ACC/AHA VHD
- [SEVERE] DOAC prescribed for a mechanical valve — switch to VKA immediately (RE-ALIGN: excess thromboembolism + bleeding) — 2020 ACC/AHA VHD

Citations

- 2020 ACC/AHA VHD Guideline + 2021 ESC/EACTS VHD Guideline [PMID:33332149](https://pubmed.ncbi.nlm.nih.gov/33332149/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 23991661) [PMID:23991661](https://pubmed.ncbi.nlm.nih.gov/23991661/)
- Cited evidence (PMID 32865375) [PMID:32865375](https://pubmed.ncbi.nlm.nih.gov/32865375/)
- Cited evidence (PMID 33196154) [PMID:33196154](https://pubmed.ncbi.nlm.nih.gov/33196154/)

Last reconciled with current guidelines: 2026-05-16.
References