KD

53 old pleasant lady underwent aortic valve replacement [21 mm Medtronic hall mechanical prosthesis] for aortic valve endocarditis with severe aortic regurgitation in 1999 (Aged 36 years).Presented with intermittent episodes of chest discomfort, palpitation and breathlessness which used to subside after 10-15 minutes since last 2 weeks.
Initial normal ECG and 2D echo revealing normal gradients across aortic valve with normal LV & prosthetic valve function

Symptomatic while in hospital and ECG showed sinus tachycardia with ST depression in leads I, II, III, augmented vector left (a VF) and V3-V6. 
Acute Coronary Syndrome was suspected as she had raised cardiac enzymes, so immediate coronary angiography was done which revealed normal coronary arteries with normal prosthetic valve opening and closing on fluoroscopy
Similar episode in ICU with hypotension & absence of click. Planned for TEE

Similar episode in echo lab and TTE at episode showed acute severe aortic regurgitation, moderate Mitral valve regurgitation with restricted prosthetic valve motion.
Intra Op TEE was done which revealed some echodense tissue underneath the valve leaflets? Pannus? thrombus
Aortic prostheses were explanted and new aortic valve was replaced using size 19 mm St Jude regent mechanical prosthesis.On follow-up,asymptomatic and normal echo findings

She was taken for surgical intervention. Intraoperative TEE was done showing high gradients. (Fig 4b). Pannus was found underneath the lesser orifice of the prosthetic valve (Fig 5a/b). Aortic prostheses was explanted and new aortic valve was replaced using size 19 mm st jude regent mechanical prosthesis. Postoperative echocardiography showed a normally functioning aortic valve, with normal gradients. Her postoperative course was uneventful, and the patient was discharged after 5 days. On follow-up, the patient is asymptomatic and normally functioning aortic prosthesis on 2D echocardiography. 

An intermittent non cyclic dysfunction may not be obvious at the time of clinical examination. So, under these conditions and as TEE cannot be repeated promptly every time, trans thoracic 2-D and Doppler echocardiography should be available at any time when symptoms develop. As this may be life threatening condition TTE is the method of choice for acute patient evaluation and urgent referral for surgical management is a rule.