Prosthetic heart valve:
which symptoms may indicate a problem

Article written and reviewed by Dr Luca Moretti

A prosthetic heart valve can function well for many years, and a new symptom does not automatically mean that it has been damaged. However, new shortness of breath, a clear reduction in exercise capacity, swelling, syncope, unexplained fever or neurological symptoms warrant more prompt assessment in someone with an artificial heart valve.
Some complications can develop slowly, while others may appear suddenly.

The safest way to recognize a problem is not to wait for a single “typical symptom,” but to compare new symptoms with the usual condition and maintain echocardiographic follow-up. Some abnormalities are in fact discovered before they cause symptoms.

Shortness of breath, fatigue and edema: when they may be related to the valve

A prosthesis that becomes too narrow or allows a significant amount of blood to leak backward can increase the workload of the heart. Dyspnea may develop during activities that were previously well tolerated, along with fatigue, reduced ability to walk or climb stairs, and ankle swelling.
These symptoms may also be caused by arrhythmias, coronary artery disease, anemia, lung problems or other conditions; their presence therefore does not allow a person to diagnose prosthetic valve dysfunction on their own.

Comparison with previous echocardiograms is particularly useful. An increase in gradients or new regurgitation may point toward prosthetic valve dysfunction and help determine which additional tests are needed.

Fever and chills: why endocarditis must also be considered

Prosthetic heart valves, including transcatheter valves, increase the risk of infective endocarditis. Persistent fever or fever without a clear explanation, chills, sweating, marked fatigue and worsening cardiac status should therefore be reported to a physician.
Endocarditis can present dramatically, but sometimes has a more gradual onset.

It is not advisable to start leftover antibiotics at home before assessment: when endocarditis is suspected, blood cultures obtained before treatment can be crucial for identifying the causative microorganism.
An ordinary fever from a respiratory infection remains much more common, but the presence of a prosthesis lowers the threshold for seeking medical advice if the clinical picture is unusual or persistent.

Prosthetic valve thrombosis and embolic symptoms

Prosthetic valve thrombosis mainly affects mechanical valves, but it can also occur in bioprostheses. A thrombus can restrict valve movement, suddenly increase gradients or become a source of emboli.
The risk in mechanical prostheses increases when anticoagulation is inadequate, but thrombosis can have more complex causes and should not automatically be attributed to a single INR value.

Sudden weakness or loss of sensation on one side of the body, difficulty speaking, facial droop, sudden loss of vision or other signs compatible with stroke require an immediate call to 112 or 118. Sudden severe dyspnea, syncope or rapid deterioration may also indicate an acute problem and should not wait for a scheduled appointment.

When a bioprosthesis deteriorates over time

Bioprostheses can develop structural valve deterioration. The leaflets may calcify, become stiff or be damaged, producing stenosis, regurgitation or both.
The process is often progressive and can be detected during echocardiographic follow-up before significant symptoms develop.

There are also problems that are not caused by deterioration of the valve material. A paravalvular leak, for example, is blood flow around the prosthesis and can cause regurgitation or, in some cases, hemolysis.
Another situation is prosthesis-patient mismatch, in which a structurally normal valve provides an effective orifice that is too small for the person’s needs.

Which tests are used when a problem is suspected

The first test is generally a transthoracic echocardiogram, compared with the examination performed after implantation. If more detailed visualization is needed, especially when endocarditis or mitral prosthesis dysfunction is suspected, a transesophageal echocardiogram may be necessary.
Computed tomography can help distinguish thrombus, pannus and leaflet abnormalities; in mechanical valves, fluoroscopy can assess the movement of the mobile components.

The 2025 ESC/EACTS guidelines recommend lifelong follow-up precisely because interpretation of a new finding depends on comparison with the previous function of the prosthesis. When symptoms are present, waiting for the annual follow-up may be inappropriate.

Frequently asked questions about warning signs of dysfunction

Which symptoms should prompt a check of the prosthesis?
New shortness of breath, reduced exercise capacity, edema, persistent palpitations, syncope, unexplained fever or neurological symptoms warrant assessment.

Does fever mean that I have endocarditis?
No. Many common infections cause fever. In people with prosthetic valves, however, persistent or unexplained fever should be reported because endocarditis is an important possibility to exclude.

Can a bioprosthesis deteriorate without symptoms?
Yes. This is why echocardiographic follow-up continues even when you feel well.

Does thrombosis affect only mechanical valves?
No. It is more typical of mechanical prostheses, but it can also occur on surgical or transcatheter bioprostheses.

When should I call 112 or 118 immediately?
In the event of sudden severe dyspnea, loss of consciousness, signs of stroke, significant chest pain or rapid deterioration in the condition.