Multiphase TAVR CT identifies unexpected sticky situation (Mechanical mitral valve leaflet dysfunction and bicuspid aortic valve)

60-year-old female with history of 33mm ATS mechanical mitral valve replacement 16 years ago for rheumatic mitral valve disease and permanent Atrial Fibrillation (AF) presented with one-year history of worsening exertional dyspnoea as well as symptom of pre-syncope. She was on warfarin for AF as well as mechanical mitral valve replacement (MVR) with therapeutic anticoagulation in the recent time. Her transthoracic echocardiogram was technically difficult as MVR leaflet motion and aortic valve morphology was not well visualised because of artefact from mechanical mitral valve (Panel 1 A: 4chamber still echo image showing reverberation artefact from mechanical mitral valve leaflets)) and aortic valve calcification. Doppler Echocardiography revealed significant aortic stenosis (AS) and mildly elevated gradients across the MVR with average peak (17 ​mmHg)/mean (6.5 ​mmHg) gradients and Effective Orifice Area (ERO) of 1.9cm2 (normal >2 cm2) at heart rate of 60bpm in AF raising a possibility of only mild mechanical prosthetic mitral valve stenosis.