Recurrent Embolic Strokes in Mechanical Aortic Valve: Diagnostic and Management Challenges.

backgroundRecurrent embolic strokes without an identifiable source in patients with mechanical heart valves pose a significant diagnostic challenge. CASE SUMMARY: A 59-year-old woman with a mechanical aortic valve experienced recurrent embolic strokes, the first nearly 7 years after implantation during subtherapeutic anticoagulation. Repeated neurologic and cardiac imaging, thrombophilia screening, and prolonged rhythm monitoring failed to identify a definitive embolic source. Fluoroscopy and computed tomography showed discrete leaflet opening restriction. Multifocal infarctions raised clinical suspicion for mechanical valve thrombosis, prompting surgical exploration that confirmed diagnosis. The valve was replaced with a bioprosthesis, and left atrial appendage occlusion was performed. The patient remained event-free at 8-month follow-up. DISCUSSION: Mechanical valve thrombosis is rare and often undetectable. This case highlights the diagnostic dilemma and importance of multidisciplinary team evaluation. TAKE-HOME MESSAGE: Recurrent embolic strokes in mechanical valve patients with inconclusive testing should prompt multidisciplinary evaluation and consideration of valve replacement.