A Case of Bioprosthetic Mitral Valve Dysfunction, Initially Presenting with Valve Thrombosis Followed by Recurrent Thrombosis and Endocarditis

Figure 1. TEE obtained upon initial presentation of the patient. (A) Midesophageal four-chamber view demonstrates a thickened mitral valve bioprosthesis with significant thrombus burden and reduced leaflet excursion. The thrombus extends to the lateral wall of the left atrium (blue arrow). (B) Midesophageal four-chamber view with color Doppler demonstrates significant flow acceleration across the mitral valve during diastole, suggestive of significant mitral valve stenosis. (C) Continuous-wave Doppler across the mitral valve in the midesophageal four-chamber window demonstrating peak velocity of 2.69 m/sec and mean gradient of 20 mm Hg across the mitral bioprosthesis, consistent with severe stenosis.

Figure 2. TEE obtained after three rounds of thrombolysis. (A) Midesophageal four-chamber view demonstrates almost complete resolution of the thrombus in the mitral bioprosthesis. Minimal amount of thrombus is noted in the ventricular aspect of the posterior mitral leaflet. The left atrial thrombus has resolved. (B) Continuous-wave Doppler across the mitral valve in the midesophageal four-chamber window demonstrating improved gradients after three rounds of thrombolysis.

Figure 3. TTE and TEE obtained upon second presentation. (A) Transthoracic study: parasternal long-axis view zoomed to the mitral valve demonstrates an echogenic mass attached in the bioprosthesis causing reduced excursion. (B) Continuous-wave Doppler across the mitral valve in the midesophageal four-chamber window demonstrating peak velocity of 2.57 m/sec and mean gradient of 19 mm Hg across the mitral bioprosthesis, consistent with recurrent severe stenosis. (C) Transesophageal study: midesophageal view at 900 demonstrates a thickened mitral bioprosthesis with recurrent thrombus and friable and mobile components prolapsing to the left atrium consistent with superimposed endocarditis.

Figure 4. TTE after mitral valve replacement. (A) A well-seated bioprosthetic valve in the mitral position with thin leaflets is demonstrated. (B) Continuous-wave Doppler across the mitral valve showed a mean gradient of 7 mm Hg.