Prosthetic Valve Thrombosis: Current Management, Surgical Treatment, and the Evolution of Thrombolysis

Prosthetic valve thrombosis (PVT) remains one of the most serious and potentially life-threatening complications of mechanical heart valves and continues to pose a major clinical challenge worldwide. Its incidence varies widely depending on anticoagulation quality, valve type, and access to specialized care, with a higher burden in regions where rheumatic heart disease remains prevalent. Historically, urgent surgery was considered the standard therapy because it provides immediate restoration of valve function; however, operative mortality is significant, particularly in critically ill patients. Over the past decades, thrombolytic therapy has emerged as an effective alternative, with increasing evidence supporting carefully monitored regimens using recombinant tissue plasminogen activator. Advances in multimodal imaging, particularly transesophageal echocardiography (TEE), have improved diagnostic accuracy, patient selection, and treatment monitoring. Contemporary studies and randomized trials have demonstrated that slow and ultraslow low-dose alteplase protocols achieve high rates of valve function recovery with lower rates of embolic and hemorrhagic complications compared with historical regimens, challenging the traditional surgical-first paradigm in selected patients. Current guidelines increasingly recognize the role of thrombolysis as part of an individualized management strategy guided by thrombus characteristics, clinical status, and institutional expertise. In conclusion, contemporary evidence indicates that slow and ultraslow low-dose alteplase-based thrombolysis represents a safe and effective therapeutic option for many patients with PVT and has become an important component of modern management strategies.