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A 66 year old woman had undergone aortic valve replacement (Björk-Shiley standard prosthesis, size 27) 23 years earlier because of severe aortic stenosis. She had since been asymptomatic and all outpatient examinations showed normal prosthetic function. She had recently undergone surgery for haemorrhoids, which required anticoagulation to be interrupted and bridged by once daily subcutaneous injections of low molecular heparin. A peak pressure gradient of 40 mm Hg was measured across the prosthesis on transthoracic Doppler echocardiography. Based on a similar heart rate, this was double that of a previous examination; therefore, obstruction of the prosthetic valve was suspected.
Transoesophageal echocardiography showed thrombotic material adjacent to the prosthesis. A cross sectional view through the aortic root revealed thrombi (arrowed) localised at the prosthetic ring protruding into the lumen. A long axis view of the ascending aorta showed flow exclusively across the major orifice by colour Doppler (not shown). The thrombotic prosthesis was excised and replaced with a bileaflet aortic valve prosthesis; her recovery was uneventful.