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A 65-year-old woman was brought to Coney Island Hospital emergency room (ER) with a history of orthopnea for 3 days associated with retrosternal chest pain, cough, and palpitations. She had undergone CABG 7 years ago with metallic mitral valve replacement for critical MS at another hospital. Her medications include Coumadin and aspirin. She claimed to not have taken Coumadin for 6 years. Her exercise tolerance was about 3 blocks. The patient denied any use of tobacco, alcohol, or drugs. On physical examinations, the patient is noted to have a pulse of 86 beats per minute, respiratory rate of 20 breaths per min, temperature of 97.78F, and a blood pressure 106/60 mm Hg. Pulse oximetry on room air was 95%. She did not have jugular venous distention, but she had reduced bilateral air entry at the bases and bilateral rales in the lower third of her lung fields. The patient was noted to have a systolic murmur without a metallic click in the mitral area. She had 2+ pulses and her abdomen was soft, nontender, and without organomegaly. The patient had no calf asymmetry and no pedal edema and her neurologic exam was grossly intact. Laboratory data revealed a normal total white blood cell count and hematocrit. Serum chemistry including electrolytes and liver function tests were within normal limits. Coagulation profile revealed a PT 12.4, PTT 31.8, INR 1.2; CPK and troponin were normal. Chest x-ray revealed cardiomegaly. There was evidence of bilateral congestion and bilateral small pleural effusion. In addition, metallic valve and metallic clips were evident on the x-ray. The electrocardiogram revealed right bundle branch block and pulmonary hypertension. In the emergency room the patient was treated as having congestive heart failure and given intravenous furosemide, beta-blockers, nitroglycerin, and heparin. The patient was admitted to the Arrhythmia Unit in Coney Island Hospital. A transthoracic echocardiogram showed inadequate tilt motion of the metallic valve and severe pulmonary hypertension. TEE revealed a mitral valve thrombus with minimal LV filling. The patient was transferred for emergency mitral valve replacement and recovered well postsurgery.Teaching PointIn any patient with a metallic valve, complete occlusion by a clot must be suspected if the patient presents with heart failure.

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