This 60-year-old male had rheumatic mitral valve stenosis treated with open mitral valvotomy in 1982, percutaneous transmitral commissurotomy in 2008 and mitral valve replacement (29 mm EPICTM bioprosthetic mitral valve) plus tricuspid valve ring annuloplasty in 2009. He remained dyspnoeic after surgery. On auscultation, the pulmonary component of the second heart sound was loud with no obvious mitral regurgitant murmur. Two separate transthoracic echocardiograms failed to demonstrate prosthetic valve dysfunction. However, transmitral gradient was disproportionately high for the prosthetic valve type (6 to 12 mm Hg, depending on heart rate) with exaggerated ventricular interdependence.
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