Recurrent Syncope 31 Years After Mitral Valve Replacement

43-year—old man was admitted to the coronary care unit because of recurrent syncope. His medical history included pulmonic valve angioplasty at age 9 years, mechani-cal mitral valve replacement because of severe mitral regur-gitation caused by congenital atrioventricular canal, and pacemaker implantation because of complete atrioventricular block. On admission he was orthopneic, his blood pressure was 78/45 mmHg, and his pulse was 72 beats per minute, irregu -lar. On auscultation, lungs were clear and there were irregular cardiac sounds of mechanical mitral prosthesis. There were no signs of peripheral edema. ECG showed slow atrial fibrillation with intermittent ventricular pacing. International normalized ratio was in high therapeutic range, at 4.5. Echo examination showed intermittent opening of the mitral valve 1:2. This was confirmed by continuous wave Doppler, M-mode echo, and color M-mode echo (Figure) with mildly elevated gradient 20/8 mmHg. Cine fluoroscopy showed intermittent open -ing of the mitral prosthesis (online-only Data Supplement Movie I; Bjork -Shiley mono-leaflet tilting disk).The patient underwent surgery. Massive calcified pan-nus covered the valve and interfered with the opening of the prosthesis.Intermittent opening of prosthetic mitral valve is rare