Conclusions:
BPVT may occur late after valve implantation and should not be confused for valve degeneration. BPVT should be suspected in patients with clinical or echocardiographic evidence of BPV dysfunction, especially when presenting within five years after valve implantation. Elevated transvalvular gradients can be the first clue in diagnosing subclinical BPVT. Anticoagulation should be instituted in hemodynamically stable patients without contraindications before pursuing repeat valve replacement. Surgery should be reserved for non-responders to anticoagulation or patients in whom hemodynamic status precludes further delay. Although the optimal duration of anticoagulation is not known, long-term anticoagulation should be considered. In the event of cessation of oral anticoagulation, antiplatelet therapy and frequent echocardiographic surveillance can be considered.