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................................................................................................................................ of paravalvular regurgitation) may reveal the most plausible underlying cause and guide clinical decision making.

Percutaneous balloon interventions should be avoided in the treatment of stenotic left-sided bioprostheses. Transcatheter valve-in-valve implantation is an option for treating degenerated BHVs in patients with increased surgical risk.227,523525 Redo-TAVI is a safe and feasible option in selected patients, but the risk of PPM in small valves and that of coronary occlusion, as well the possibility for future access to the coronary arteries need to be considered.229,526528 Experience is mostly in aortic BHVs and remains limited for BHVs in the mitral position and even more so in the tricuspid position529532 for which valvein-valve procedures may be reasonable in patients at increased surgical risk.531,533 Valve-in-ring mitral procedures are also acceptable in selected candidates, while the role of valve-in-ring tricuspid procedures remains uncertain. It is necessary for the Heart Team to discuss every patient and choose the best individualized approach. Careful preprocedural planning is needed to minimize the risk of coronary artery obstruction and enable future coronary re-access in aortic BHV reinterventions if necessary. For mitral re-interventions the risk of LVOT obstruction should be carefully evaluated.534

11.4.2 Non-structural valve dysfunction 11.4.2.1 Patient-prosthesis mismatch Patient-prosthesis mismatch (PPM) significantly decreases long-term survival, correlates with SVD and increases readmission rates for both heart failure and reoperation.535537 Efforts to prevent PPM should receive more emphasis to improve long-term survival after either SAVR or TAVI.538

11.4.2.2 Paravalvular leak and haemolysis Blood tests for haemolysis should be part of routine follow-up after valve replacement. Diagnosis of haemolytic anaemia requires TOE to detect paravalvular leaks for prostheses in the mitral position if TTE is not contributory. Reoperation is recommended if the paravalvular leak is related to endocarditis or causes haemolysis requiring repeated blood transfusions or leading to severe symptoms. Transcatheter closure of a paravalvular leak is feasible, but experience is limited and there is presently no conclusive evidence to show consistent efficacy.539 Transcatheter closure of paravalvular leaks should be considered for anatomically suitable paravalvular leaks in candidates selected by the Heart Team.540 Medical therapy (including iron supplementation, beta-blockers, and erythropoietin) is indicated in patients with severe haemolytic anaemia when contraindications to surgical or transcatheter closure are present.540

11.4.3 Endocarditis The management of patients with endocarditis should follow the relevant guidelines.4

11.4.4 Thrombosis 11.4.4.1 General comments Obstructive valve thrombosis should be suspected promptly in any patient with any type of prosthetic valve who presents with recent dyspnoea or an embolic event. The diagnosis should be confirmed by TTE and TOE, cinefluoroscopy, or CCT if promptly available.268,314 Valve thrombosis occurs mainly in MHVs. However, cases of thrombosis of BHVs have also been reported after surgery or transcatheter valve implantation.541 Thrombus on BHVs can present as hypo-attenuated leaflet thickening (HALT) with relatively normal leaflet motion, HALT with reduced leaflet motion but normal gradients, and clinical valve thrombosis with elevated gradients. Distinguishing between thrombus and pannus by means of CCT is important to guide decision making.

11.4.4.2 Valve thrombosis The management of MHVs thrombosis is high risk, whatever the option taken. Fibrinolysis carries risks of bleeding, systemic embolism, and recurrent thrombosis.542 Emergency valve replacement is recommended for obstructive prosthetic valve thrombosis in critically ill patients without a contraindication to surgery. Management of nonobstructive thrombosis of an MHV depends mainly on the occurrence of a thromboembolic event and the size of the thrombus. Surgery should be considered for a large (>10 mm) non-obstructive prosthetic valve thrombus that is complicated by embolism or persists despite optimal anticoagulation.543 Fibrinolysis may be considered if surgery is not an option or is very high risk for the treatment of thrombosis of right-sided prostheses, but carries a risk of bleeding and thromboembolism. Anticoagulation using a VKA and/or UFH is the first-line treatment of BHV thrombosis. Because BHV thrombosis is associated with recurrence and early prosthetic degeneration, indefinite anticoagulation should be considered after a confirmed episode, but this strategy must be balanced against an increased risk of bleeding544,545 (Figure 10).

11.4.4.3 Subclinical leaflet thrombosis HALT is detected by CCT in 12.4% and 32.4% of TAVI patients on OAC or DAPT at 3 months, respectively.546 The clinical significance of these findings is uncertain. Selective use of oral anticoagulants in patients with confirmed HALT and restricted leaflet motion with elevated gradients should be considered.

11.4.5 Heart failure Heart failure after valve surgery should lead to a quick search for SVD or PPM, deterioration of repair, LV dysfunction, or progression of another valve disease. Non-valvular-related causes such as CAD, hypertension, or sustained arrhythmias should also be considered. The management of patients with heart failure should follow the relevant guidelines and consensus documents.142,247

Recommendations on management of prosthetic valve dysfunction

Recommendations Classa Levelb

Mechanical prosthetic thrombosis Urgent or emergency valve replacement is recommended for obstructive thrombosis in critically ill patients without serious comorbidity.542 I B Fibrinolysis (using recombinant tissue plasminogen activator 10 mg bolus þ 90 mg in 90 min with UFH or streptokinase 1 500 000 U in 60 min without UFH) should be considered when surgery is not available or is very high risk, or for thrombosis of right-sided prostheses.542 IIa B

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