Prosthetic valve thrombosis: contemporary concepts in diagnosis and management.

Abstract

Introduction: Prosthetic valve thrombosis (PVT) is a serious, potentially life-threatening complication of mechanical heart valves. Its management remains challenging, with persistent debate regarding the optimal roles of surgery and thrombolytic therapy.

Areas covered: This review summarizes contemporary approaches to the diagnosis and management of PVT, based on evidence from observational studies, randomized trials, and major guideline documents. Literature was identified through a PubMed search from inception to March 2026, supplemented by manual review of relevant references. We discuss the role of echocardiography and multimodality imaging in diagnosis, thrombus characterization, and therapeutic decision-making. Evidence comparing surgery and thrombolysis is reviewed, including historical outcomes with conventional thrombolytic regimens and contemporary data using low-dose, slow- or ultraslow-infusion protocols. Recent randomized evidence, including SAFE-PVT and TENET, is considered in the context of current practice.

Expert opinion: Management of PVT has shifted from a surgery-dominant paradigm toward individualized, imaging-guided decision-making. In selected patients, standardized fibrinolytic protocols now offer high success rates with acceptable safety, particularly where surgical risk or access is limiting. Surgery remains essential for patients with contraindications to thrombolysis, large thrombus burden, recurrent thrombosis, or failed fibrinolysis.