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A 28-year-old man with idiopathic dilated cardiomyopathy who had had St. Jude aortic- and mitral-valve replacements 3 years earlier presented with decompensated heart failure. The examination was notable for marked jugular venous distention, an S3 gallop, and a palpable left ventricular heave. The carotid upstrokes were normal, but the prosthetic second heart sound was diminished. A grade 2/6 systolic murmur was audible at the right upper sternal border. The international normalized ratio was 3.0 and had been within the therapeutic range consistently over the previous months. Valve fluoroscopy confirmed immobilization of one of the mechanical aortic-valve leaflets, consistent with obstruction of the prosthetic valve (Video 1). Surgical intervention and thrombolytic therapy were considered but were deferred in this patient, considered to be at surgical risk, in favor of ongoing anticoagulation therapy with warfarin and placement on a waiting list for cardiac transplantation. Repeat fluoroscopy performed 6 months later during right heart catheterization for purposes of surveillance because he was on a waiting list revealed normal bileaflet motion of the aortic-valve prosthesis, indicating spontaneous thrombolysis (Video 2). Fortunately, the patient exhibited no signs or symptoms of an intercurrent cardioembolic event. He continues to await cardiac transplantation.
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