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A 51-year-old man presented to other hospital with onset dyspnea on exertion. Earlier he had aortic and mitral valve replacement with a bileaflet mechanical prosthesis. Later he developed obstructive prosthetic mitral valve thrombosis (OPMVT). He underwent urgent surgery, with removal of the prosthetic mitral valve and thrombus. Latest, he had a transient ischemic attack. This time he was given intravenous diuretics and heparin, and was transferred to our hospital. Clinical history and physical examination suggested probable prosthetic valve thrombosis. Because of poor transthoracic echocardiography, we resorted to two-dimensional and real-time three-dimensional transesophageal echocardiography (2D TEE, RT3DTEE) 1) and these showed that one leaflet (L2) was opening fully, while the other leaflet (L1) was completely blocked by a small thrombus (Fig. 1A and B, Supplementary movie 1 and Supplementary movie 2). The mean mitral gradient was 23 mmHg, and pressure half-time was 296 msec. We opted for medical treatment2) using intravenous heparin for ten days followed by oral anticoagulation adjusted to a target international normalized ratio (INR) of 3.0-3.5. Aspirin 100 mg daily was initiated with the heparin. Daily INR was started for close monitoring of anticoagulation. The patient's presenting symptoms resolved. Weekly follow-up TEE was carried out. At the end of fourth week this showed normal function of mitral prosthesis, as well as resolution of the small thrombus mentioned (Fig. 1C and D, Supplementary movie 3 and Supplementary movie 4). Medical treatment under TEE monitoring, with spatial assessment of the OPMVT gathered by RT3DTEE, may be considered as a first-line treatment of OPMVT.    Fig. 1  Two dimensional transesophageal echocardiogram (2D TEE) showing one leaflet (L1) blocked, while the second leaflet (L2) is opening with accelerated color flow velocity (A). Real time three dimensional transesophageal echocardiogram (RT3DTEE) view from ...

journal of cardiovascular ultrasound

A Successful Dissolution of an Obstructive Prosthetic Mitral Valve Thrombus: Sequential Two and Three Dimensional Transesophageal Echocardiography Examination