A 46-year-old male with both mechanical aortic (AVR) and mitral valve (MVR) replacements presented with new-onset dyspnoea and transient visual field deficits. The patient had both bi-leaflet ATS mechanical valves implanted 8 years earlier for infective endocarditis. The patient was non-compliant with his warfarin for at least 5 months prior to presentation with an INR of 1.2. A transthoracic echocardiogram (TTE) demonstrated a 12 × 9 mm echodense mass attached to the ventricular surface of the mechanical MVR, most consistent with a thrombus (Panel A, Supplementary material online, Video S1ASupplementary material online, Video S1A). The peak and mean gradients across the MVR in diastole were 42 and 27 mmHg, respectively (Panel B). Two-dimensional and three-dimensional (3D) transesophageal echocardiography (TEE) demonstrated that the MVR was encased with diffuse thrombus, limiting motion of both leaflets (Panels C and D, Supplementary material online, Videos S1C, DSupplementary material online, Videos S1C, D). The mechanical AVR was functioning normally. Although a preoperative cardiac catheterization revealed no evidence of obstructive coronary artery disease, cinefluoroscopy confirmed that one leaflet of the MVR was severely restricted (Panel E, Supplementary material online, Video S1ESupplementary material online, Video S1E). Following immediate anticoagulation with heparin, the patient was taken emergently to the operating room for urgent MVR and AVR with bioprosthetic valves. The explanted MVR demonstrated extensive thrombus burden on both the atrial and ventricular surfaces of the valve, similar in appearance to the preoperative 3D TEE images (Panel F). Recognizing the challenges in the non-invasive diagnosis of mechanical valve thrombosis, multimodality imaging with TTE, 3D TEE, and cinefluoroscopy provide complementary information for this catastrophic complication.

中文翻译：

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机械二尖瓣血栓形成：发粘情况。

一位46岁的男性同时患有机械主动脉（AVR）和二尖瓣（MVR）置换，表现为新发呼吸困难和短暂性视野缺损。该患者均在8年前因感染性心内膜炎而植入了双叶ATS机械瓣膜。患者在出院前至少5个月未遵从华法林，INR为1.2。经胸超声心动图（TTE）显示附着在机械MVR心室表面的12×9 mm回声质量，与血栓最一致（面板A，在线补充材料，视频S1A，在线补充材料，视频S1A）。舒张期跨MVR的峰值和平均梯度分别为42和27 mmHg（图B）。二维和三维（3D）经食道超声心动图（TEE）显示，MVR包裹有弥漫性血栓，限制了两个小叶的运动（面板C和D，在线补充材料，视频S1C，D补充材料在线，视频S1C， D）。机械AVR正常运行。尽管术前心脏导管检查未发现阻塞性冠状动脉疾病的证据，但电影透视检查证实，MVR的一张传单受到严重限制（面板E，在线补充材料，视频S1E在线补充材料，视频S1E）。立即用肝素进行抗凝治疗后，将患者紧急带到手术室，用生物人工瓣膜紧急进行MVR和AVR。移植的MVR在瓣膜的心房和心室表面均表现出广泛的血栓负担，外观与术前3D TEE图像相似（图F）。认识到机械瓣膜血栓形成的非侵入性诊断中的挑战，采用TTE，3D TEE和电影透视检查的多模态成像可为这种灾难性并发症提供补充信息。