A Woman with Fatigue and Dyspnea

This 64-year-old woman had aortic and mitral mechanical valve replacements decades ago. She was appropriately anticoagulated and had no evidence of bleeding. Discovery of normocytic anemia prompted testing that included echocardiography, which confirmed a pannus (fibrovascular ingrowth) leading to severe stenosis of the mechanical aortic valve. One year after surgical redo aortic valve replacement, she presented again, with 6 months of progressive fatigue, exertional dyspnea without overt signs of congestive heart failure, and hemoglobinuria (see Figure 1). This time, her workup led to the diagnosis of shear-mediated intravascular hemolysis from paravalvular regurgitation around her mechanical mitral valve.