This 88-year-old woman presented with worsening heart failur | Figure 1

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This 88-year-old woman presented with worsening heart failure and hemoptysis. She had undergone bioprosthetic mitral valve replacement 12 years ago for severe mitral stenosis with an early postoperative baseline echocardiogram that showed normal LV and RV size and function, normal prosthetic valve function, and a pulmonary systolic pressure of 40 mm Hg. On exam now she has a blood pressure of 100/70 mm Hg, heart rate of 74 bpm with an irregular pulse, a jugular venous pressure of 20 cm H2O, distant heart sounds, and bilateral pulmonary rales. The following Doppler tracings were recorded on the current study.

The most likely cause of her current symptoms is:

A. Pulmonary embolus
B. LV systolic dysfunction
C. Severe mitral regurgitation
D. Rheumatic aortic valve disease
E. Mitral stenosis

Prosthetic valve thrombosis is a rare and severe complication of the mechanical prosthetic valve. Management can be challenging due to varying clinical presentation, overlapping features of differential diagnosis, and lack of randomized controlled trials on the therapeutic options. In this article, we report the case of a patient with a mechanical prosthetic mitral valve presented with symptoms of heart failure, and an echocardiography showing increased mean pressure gradient across the prosthesis along with a fixed posterior leaflet and a partially restricted anterior leaflet with no visible mass. That raised the concern for an obstructed prosthesis. After multimodality imaging and multidisciplinary team discussions, prosthetic valve thrombosis diagnosis was favored over other different diagnoses that included but not limited to pannus ingrowth. Fibrinolytic therapy was administrated, and the patient was discharged on optimal anticoagulation. Repeated echocardiography a month later showed normal mean gradient and normal functioning prosthetic mitral valve without the need for repeat mitral valve surgery.

Shone complex (SC) is a rare congenital heart disease characterized by four obstructive anomalies, including parachute mitral valve (PMV), left atrial supra-valvular ring, subaortic stenosis, and coarctation of the aorta. Typically, SC manifests early in life. However, we encountered a 52-year-old female with a history of hypertension diagnosed at 26 years and left-sided weakness poststroke. She presented with worsening dyspnea and palpitations, prompting a thorough investigation. Echocardiography revealed a heavily calcified bicuspid aortic valve with severe aortic stenosis and parachute mitral valve with severe mitral stenosis and preserved ejection fraction, raising suspicions regarding the presence of SC. Cardiac catheterization, aortic-angiography, and noncontrast chest computed tomography (CT) revealed abrupt occlusion of the postductal aorta, giving a picture of aortic coarctation with well-established collateral vessels including prominent right and left internal mammary arteries. So, she was diagnosed with an incomplete SC at the age of 52. Shone complex is a rare congenital heart disease that typically presents in early childhood, but late presentations due to misdiagnosis or incomplete work up are possible. This case emphasizes the rarity of late presentations of SC and highlights the importance of early diagnosis and intervention to improve outcomes. An incomplete SC should be considered in adult patients presenting with left-sided obstructive lesions.

Still of deployment of Edwards Sapien 3 valve for mitral valve-in-valve replacement. Patient previously had bio prosthetic mitral valve placed approximately 7 years ago which became severely stenosed resulting in pulmonary hypertension and right heart failure.

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