Table 64. Step 1: Diagnosis of prosthetic valve thrombosis.

	Characteristics of prosthesis thrombosis
Clinical evaluation	Symptoms and signs suggestive of acute or exacerbated heart failure (dyspnea, chest pain, low output, or syncope) Murmur compatible with stenotic valvular heart disease Muffled clicking sound Possibility of ineffective anticoagulation (INR outside therapeutic range)
Electrocardiogram	Compatible with the baseline disease that was the reason for valve surgery Rarely shows acute alteration
Chest radiography	Compatible with the baseline disease that was the reason for valve surgery Rarely shows acute alteration of the cardiac silhouette Pulmonary congestion may be present
Echocardiogram	Key test for diagnosis Ideally transesophageal Documentation of thrombus adhering to the prosthesis, identification of location and size of the thrombosis
Hemodynamic study (fluoroscopy)	Inadequate mobility of one or more leaflets of the mechanical prosthesis

INR: international normalized ratio.