Launched on 6th of October 2026

Cardio.toolsby Mohamed Ghazy, MD CardiologyAin Shams University, Egypt · Cardiology Consultant, Saudi ArabiaScopus ID: 55257919100
Echocardiography & valvular

Prosthetic valve assessment

Grades aortic and mitral prosthesis Doppler against ASE/EACVI criteria and calculates indexed EOA for patient–prosthesis mismatch. Sets the ESC and ACC/AHA antithrombotic plans for mechanical, surgical bioprosthetic and TAVI valves side by side, including INR targets by prosthesis thrombogenicity, aspirin, DOAC contraindications and valve-thrombosis management. ESC tags refer to the 2021 ESC/EACTS guideline; check them against the 2025 update.

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Prosthesis
Prosthesis thrombogenicity (ESC)
Doppler
Aortic prosthesis criteria (ASE / EACVI). Enter what you measured
Normal
< 3
Possible
3–4
Significant
> 4
Normal
< 20
Possible
20–35
Significant
> 35
Normal
≥ 0.30
Possible
0.25–0.29
Significant
< 0.25
Normal
> 1.2
Possible
0.8–1.2
Significant
< 0.8
Normal
< 80
Possible
80–100
Significant
> 100
Patient factors
Set INR targets and the need for anticoagulation
Aortic mechanical · 0 Doppler parameters
Antithrombotic plan
Risk factor for INR target: no
Antithrombotic therapy
ESC
  • Lifelong VKA, target INR 2.5
    Class IESC 2021
    Median target set by prosthesis thrombogenicity and patient risk factors (mitral/tricuspid position, prior thromboembolism, AF, mitral stenosis, LVEF < 35%). INR self-management recommended in trained patients.
  • DOACs contraindicated
    IIIESC 2021
    Excess thrombosis and bleeding with dabigatran (RE-ALIGN) and apixaban with On-X (PROACT Xa).
ACC/AHA
  • Lifelong VKA, target INR 2.5
    Class IACC/AHA 2020
    Bileaflet or current-generation tilting-disc aortic valve without risk factors.
  • Add aspirin 75–100 mg
    IIbACC/AHA 2020
    May be considered when bleeding risk is low (downgraded from routine use in 2014).
  • DOACs contraindicated
    IIIACC/AHA 2020
    Excess thrombosis and bleeding with dabigatran (RE-ALIGN) and apixaban with On-X (PROACT Xa).
Valve thrombosis
ESC
  • Obstructive mechanical valve thrombosis
    Class IESC 2021
    Urgent or emergency surgery. Fibrinolysis only if surgery is not available or very high risk, or for right-sided valves.
ACC/AHA
  • Symptomatic mechanical valve thrombosis
    Class IACC/AHA 2020
    Either slow-infusion low-dose fibrinolysis or emergency surgery, chosen by the Heart Team on thrombus size, NYHA class, surgical risk and local expertise.

Get a baseline TTE 6 weeks to 3 months after implantation. Later studies are judged against it.

References
  1. Zoghbi WA, et al. Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound (ASE). J Am Soc Echocardiogr 2009;22:975-1014.
  2. Lancellotti P, et al. Recommendations for the imaging assessment of prosthetic heart valves (EACVI). Eur Heart J Cardiovasc Imaging 2016;17:589-590.
  3. VARC-3 Writing Committee. Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research. Eur Heart J 2021;42:1825-1857.
  4. Vahanian A, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2022;43:561-632.
  5. Otto CM, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease. Circulation 2021;143:e72-e227.
  6. Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2025.
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