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A 38-year-old man came to the emergency room owing to progressive effort dyspnoea which had started 3 weeks previously. During recent days he reported episodes of presyncope at minimal efforts or even at rest. His past medical history indicated aortic valve replacement with a St Jude bileaflet mechanical prosthesis at age 26 owing to severe aortic regurgitation associated with aortic bicuspid valve. He reported irregular use of oral anticoagulants and current smoking.
Physical examination showed a harsh systolic ejection murmur, and the valvular click was inaudible. Transthoracic echocardiography disclosed severe stenosis and severe insufficiency of the mechanical aortic valve, with a mean gradient of 74 mm Hg. Cinefluoroscopy showed minimal opening of leaflets of the mechanical prosthesis (panels A and B and online video).
Cinefluoroscopy is a simple and accurate method both for the diagnosis of St Jude valve thrombosis and for following the response to treatment. In a normal functioning St Jude bileaflet mechanical valve, the angulation between leaflets is about 10° when the valve is open and 120° when it is closed. In this patient the valve had minimal movement, with angulation between leaflets of 57° when open (panel A) and 89° when closed (panel B). The patient underwent successful surgical thrombectomy and was discharged home seven days later with no cardiovascular symptoms. Postoperative cinefluoroscopy (panels C and D and online video) showed opening angle of 13° and closing angle of 126°. Transthoracic echocardiography disclosed a mean aortic gradient of 14 mm Hg.