Management of Patients with Bioprosthetic Tricuspid Valve

Monitoring and Surveillance

The American College of Cardiology recommends an initial transthoracic echocardiography (TTE) study after prosthetic valve implantation to establish baseline valve hemodynamics, and repeat TTE is recommended if there is a change in clinical symptoms or signs suggesting valve dysfunction 2, 3
The American College of Cardiology also recommends transesophageal echocardiography (TEE) when clinical symptoms or signs suggest prosthetic valve dysfunction 2, 3
Annual TTE is reasonable in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status, as recommended by the American College of Cardiology 2, 3

The American College of Cardiology recommends warfarin therapy to achieve an INR of 2.0-3.0 for 3-6 months after implantation, to prevent early thromboembolism while the prosthetic valve is being endothelialized 1, 4
Lifelong low-dose aspirin therapy is reasonable after the initial anticoagulation period, as recommended by the American College of Cardiology 1
For patients with decreased right ventricular function or other thromboembolic risk factors, long-term anticoagulation with warfarin to achieve an INR of 2.0-3.0 may be reasonable, according to the American College of Cardiology 1

The American College of Cardiology recommends repeat TTE if there is a change in clinical symptoms or signs suggesting valve dysfunction, and TEE is recommended when clinical symptoms or signs suggest prosthetic valve dysfunction 2, 3
For patients with symptoms due to severe primary tricuspid regurgitation (TR) that are unresponsive to medical therapy, tricuspid valve surgery can be beneficial, as stated by the American College of Cardiology 3
The European Society of Cardiology notes that transcatheter valve-in-valve implantation is now an option for treating degenerated bioprostheses in patients with increased surgical risk 5
Blood tests for hemolysis should be part of routine follow-up after valve replacement, and lactate dehydrogenase levels relate to the severity of hemolysis, according to the European Society of Cardiology 5
If a paravalvular leak is causing hemolysis requiring repeated blood transfusions or leading to severe symptoms, reoperation is recommended by the European Society of Cardiology 5

The American College of Cardiology recommends that the choice of valve intervention (repair or replacement) and type of prosthetic heart valve should be a shared decision-making process that accounts for the patient's values and preferences 2
A bioprosthetic valve is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, as stated by the American College of Cardiology 2

Inadequate anticoagulation in the early post-implantation period may increase the risk of thromboembolism, according to the American College of Cardiology and the Journal of the American College of Cardiology 1, 4
Failure to monitor for signs of valve dysfunction may lead to delayed diagnosis of complications, as noted by the American College of Cardiology 2, 3
The risk of bioprosthetic valve deterioration increases significantly after 10 years, necessitating more vigilant monitoring, according to the American College of Cardiology 2, 3
Patients with bioprosthetic tricuspid valves who develop symptoms should be evaluated promptly with appropriate imaging to assess for valve dysfunction, as recommended by the American College of Cardiology 2, 3