skip to main content

Prosthetic valve dysfunction — ABIM Board MCQ

Instant feedback + full explanation. One question, done properly.

ModerateCardiovascularProsthetic valve dysfunctionABIM Board

A 70-year-old man with a mechanical mitral valve presents with progressive exertional dyspnea. His INR has been below its target range for several weeks. Transthoracic echocardiography shows newly elevated gradients across the prosthetic valve, but the valve leaflets cannot be adequately visualized because of acoustic shadowing. Which of the following is the most appropriate next diagnostic study to evaluate the suspected prosthetic valve obstruction?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Transesophageal echocardiography

The correct answer is D. Progressive dyspnea, several weeks of subtherapeutic anticoagulation, and a newly elevated prosthetic mitral-valve gradient strongly suggest mechanical prosthetic-valve obstruction due to thrombosis, although pannus is an alternative cause. TEE is the best next listed study because it can define the cause and severity of obstruction and identify thrombus or associated regurgitation when TTE visualization is limited. ACC/AHA guidance recommends TTE and TEE in suspected prosthetic-valve stenosis; fluoroscopy or cine-CT may additionally assess mechanical leaflet motion. Repeating TTE only after restoring anticoagulation would delay diagnosis and treatment. Exercise stress testing is inappropriate when obstruction is already suspected at rest. Invasive catheterization is not the first-line diagnostic test, and ventilation-perfusion scanning would evaluate pulmonary embolism rather than the documented prosthetic-valve abnormality.

Reference: Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease, sections on Diagnosis of Acute Mechanical Valve Thrombosis and Diagnosis of Prosthetic Valve Stenosis. 2020. https://www.heart.org/en/-/media/phd-files-2/science-news/2/2020/2020_acc_aha_guideline_for_the_management_of_patients_with_valvular_heart_disease_slide_set.pdf