A 52-year-old with a mechanical mitral valve (on warfarin, INR 1.4) presents with acute dyspnoea, muffled mechanical clicks on auscultation, and pulmonary oedema. How do you proceed?

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Acute prosthetic valve thrombosis is a **time-critical valvular emergency**. The classic triad here — subtherapeutic INR, muffled mechanical clicks, and acute heart failure — makes this the top diagnosis.

**ABCDE.** Sit upright, high-flow O2, **CPAP** for pulmonary oedema, cautious IV furosemide, arterial line. Bloods including FBC, U&E, LFTs, coagulation, **INR**, troponin, LDH (mechanical haemolysis), blood cultures (exclude IE), group and save.

**Imaging — urgent.** Bedside **TTE** to assess LV function, mitral gradient, and pulmonary pressures, followed by **transoesophageal echo** which is the test of choice for the prosthetic mitral valve — leaflet motion, thrombus dimensions, distinction from pannus. **Cine fluoroscopy** of the valve confirms restricted leaflet motion.

**Anticoagulate now.** Start **therapeutic IV unfractionated heparin** while imaging proceeds — easily reversible if surgery is chosen.

**Definitive therapy — Heart Valve MDT.** Per **ESC valvular heart disease 2021**, decision making is multidisciplinary:
- **Emergency redo valve surgery** is first-line for left-sided prosthetic thrombosis with **NYHA III–IV symptoms** or a **mobile / large thrombus >0.8 cm²**.
- **Fibrinolysis** is reserved for patients with high surgical risk, smaller thrombi, or right-sided valves; risks include embolic stroke and bleeding.

I would phone the **on-call cardiothoracic surgeon and the tertiary cardiology centre** immediately, transfer if needed, and run a parallel anaesthetic and ITU workup.

**Address the precipitant.** Why was the INR 1.4 — missed doses, antibiotics, dietary change, recent procedure with bridging error? This drives prevention.

**Communication.** Honest, careful conversation with the patient and family about high-risk emergency surgery, mortality, and alternatives. Document INR history, contact the anticoagulation clinic, and Datix if there was a system failure in INR management.

Suspected acute prosthetic valve thrombosis

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