Investigations
A transthoracic echocardiogram (TTE) revealed a moderately to severely reduced left ventricular systolic function with an estimated ejection fraction of 30-35%, moderate transvalvular aortic regurgitation, with increased transprothetic pressure gradients. Prosthetic transvalvular velocities (Vmax 3.55m/s) were increased with peak gradient of 51 mmHg and mean gradient of 32 mmHg [Figure 1]. A transesophageal echocardiogram (TEE) revealed an abnormally functioning mechanical valve with transvalvular peak gradient of 49 mmHg, mean gradient of 29 mmHg, Doppler velocity index of 0.21 and acceleration time of 114msec, consistent with prosthetic aortic valve stenosis [video 1, Figure 2]. Leaflet mobility and sub valvular structures could not be evaluated because of acoustic shadowing on esophageal views. Valve fluoroscopy revealed an immobile disc without any obvious obstructive lesions [video 2]. A Multi detector computed tomography (MDCT) was performed to help in assessing the etiology of valve dysfunction. It revealed a low-density lesion (40HU), consistent with thrombus, measuring 8 x 5 mm interfering with the mobility of the posterior disc of the Prosthetic Aortic Valve [Figure 3].