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A 69 year old man was admitted to our hospital because of an episode of acute severe dyspnoea associated with transient loss of consciousness. His medical history revealed rheumatic aortic stenosis for which he had undergone aortic valve replacement with a No. 23 Duromedics bileaflet prosthesis in 1984. Since then, he had received adequate anticoagulant treatment and his condition had been fairly good. At admission auscultation revealed normal prosthetic valvar opening and closing clicks and a grade 2/6 ejection systolic murmur. An ECG showed normal sinus rhythm with evidence of left ventricular hypertrophy. Transthoracic echocardiography was performed to evaluate prosthetic valve function. A cyclic (every 30–60 beats) failure in closure of a leaflet was seen, resulting in acute massive aortic regurgitation. In these “sporadic” cycles continuous wave Doppler (upper panel) showed the absence of closing click, followed by the signal of acute massive regurgitation (slope of the diastolic regurgitant jet > 3 m/s) with an increase in the velocity of forward aortic flow in subsequent systole. Colour flow showed a two dimensional display of the aortic regurgitation jet (mid panel). The patient underwent cardiac catheterisation for further evaluation. The prosthetic valve disk motion visualised by cineradiography (lower panel) showed a sporadic failure of closure of a tilting leaflet that resulted in massive aortic regurgitation. At surgery no pannus was seen and the aortic valve was replaced with a No. 21 Carpentier-Edwards prosthesis. Mechanical tests revealed fatigue/structural valve deterioration of the sewing ring at the level of the pivoting mechanisms.