Bioprosthetic Valve Thrombosis

A 50-year-old male with a history of bioprosthetic mitral valve replacement in 2002 presented with progressive dyspnea on exertion and lower extremity edema. Upon admission, a transesophageal echocardiogram revealed thickened bioprosthetic mitral valve cusps with reduced leaflet excursion resulting in severe mitral regurgitation and stenosis (Fig. 1A and 1B). Both surfaces of the leaflets appeared to have a thick uniform coating of thrombus extending toward the intraatrial septum (Fig. 1C). In addition, a large thrombus was noted in the left atrial appendage (Arrow, Fig. 1C). Due to the patient’s symptoms and presence of a stenotic bioprosthetic mitral valve, surgical intervention was pursued. The mitral valve was successfully replaced with a 27-mm Medtronic mosaic bioprosthetic valve; surgical excision confirmed the presence of a large, adherent thrombus attached to both surfaces of the bioprosthetic valve (Fig. 1D). With the degree of thrombus, a hypercoaguable work-up was performed, revealing homocystenemia. The patient’s postoperative course otherwise was uncomplicated with no evidence of thromboem-