Recommendations K. 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 + 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
Surgery should be considered for large (>10 mm) non-obstructive prosthetic thrombus complicated by embolism.	IIa	C
Bioprosthetic thrombosis
Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering re-intervention.	I	C
Anticoagulation should be considered in patients with leaflet thickening and reduced leaflet motion leading to elevated gradients, at least until resolution. 541,546	IIa	B
Haemolysis and paravalvular leak
Reoperation is recommended if a paravalvular leak is related to endocarditis or causes haemolysis requiring repeated blood transfusions or leading to severe heart failure symptoms.	I	C
Transcatheter closure should be considered for suitable paravalvular leaks with clinically significant regurgitation and/or haemolysis in patients at high or prohibitive surgical risk. 547	IIa	B
Decision on transcatheter or surgical closure of clinically significant paravalvular leaks should be considered based on patient risk status, leak morphology, and local expertise.	IIa	C
Bioprosthetic failure
Reoperation is recommended in symptomatic patients with a significant increase in transprosthetic gradient (after exclusion of valve thrombosis) or severe regurgitation.	I	C
Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered by the Heart Team depending on anatomic considerations, features of the prosthesis, and in patients who are at high operative risk or inoperable. 529	IIa	B
Transcatheter valve-in-valve implantation in the mitral and tricuspid position may be considered in selected patients at high risk for surgical reintervention. 382,531,532	IIb	B
Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction if reoperation is low risk.	IIa	C
UFH: unfractionated heparin; VKA: vitamin K antagonist. aClass of recommendation. bLevel of evidence.