Lost and Found: Catastrophic En Block Embolism of a Mechanical Prosthetic Valve Thrombus after Thrombolytic Therapy

A 45-year-old woman presented with refractory pulmonary oedema secondary to a massive thrombosis of a st. jude mechanical mitral prosthetic valve. she was noncompliant with warfarin and had suffered embolic stroke 3 years earlier, from which she had recovered. she was in sinus rhythm with absent valve clicks on auscultation. a transthoracic echocardiogram revealed a high transmitral peak gradient of 34 mmhg and a mean gradient of 27 mmhg with an ejection fraction of 55% [figure 1a]. the international normalised ratio (inr) was 1.29. an urgent transesophageal echocardiogram (tee) demonstrated a large (6 cm2) left atrial thrombus attached to the mechanical valve at the discs which were stuck in a closed position