Transthoracic echocardiography of a 40 year old man showing a thrombosis of a Björk-Shiley mechanical valve prosthesis in the mitral position. The patient had received Björk-Shiley prostheses in the mitral and aortic positions 25 years earlier because of rheumatic degeneration of the valves. He had chronic atrial fibrillation and a reduced left ventricular function. He presented with rapidly progressive dyspnoea and orthopnoea. He successfully underwent intravenous thrombolysis followed a few days later by a mitral valve prosthesis replacement. (Top left, artistic representation of the thrombus on the prosthesis. Note the acoustic shadow produced by the prosthesis in the left atrium. Top right, magnification of the thrombosed prosthesis. LA, left atrium; LV, left ventricle; RA, right atrium; LA, left ventricle.)

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