Unexpected cause of persistent hemolytic anemia

323 A 66‐year‐old farmer with 2 old‐type Lillehei‐ ‐Kaster mechanical mitral and aortic valve pro‐ stheses implanted 30 years earlier was admit‐ ted to the hospital due to a 6‐month history of progressing exertional dyspnea (New York He‐ art Association class III). He had no history of fever or chills. On admission, the patient was hemodynamically stable, with a slight jaundi‐ ce. Auscultation revealed an apical systolic mur‐ mur. Laboratory tests showed severe anemia (he‐ moglobin, 87 g/l; red blood cells, 2.5 × 1012/l; he‐ matocrit, 0.27; normal eosinophil count), hy‐ perbilirubinemia (49.9 μmol/l), and normal se‐ rum iron and ferritin levels. Transthoracic and