A 74 year old woman with mixed mitral valve disease presented with episodes of loss of consciousness and fainting. The attacks were noted to be closely related to posture, especially crouching, and this, with the clinical finding that the radial pulse disappeared before she lost consciousness, suggested the diagnosis of a ball valve thrombus. Cardiac catheterisation confirmed the diagnosis but was followed by a fall in blood pressure necessitating emergency surgery. The only position in which the circulation could be maintained was the right lateral, with steep head down tilt, and left femoro-femoral cardiopulmonary bypass had to be established in this position. Operation confirmed the presence of a ball valve thrombus and the patient recovered uneventfully.
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