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A 44-year–old woman underwent mitral valve and tricuspid valve (TV) replacement 6 years earlier using an ATS bileaflet tilting disc prostheses (ATS Medical Inc., Minneapolis, MN) for combined valvular stenosis and regurgitation because of rheumatic heart disease. On a routine clinic visit, the patient reported progressive fatigue and pedal edema over the previous few weeks. On physical examination, she was hemodynamically stable with evidence of elevated jugular venous pressure, hepatomegaly, and 3-mm pitting ankle and leg edema. Cardiac auscultation revealed closing and opening mechanical clicks; however, mitral and tricuspid clicks could not be distinguished. A grade 2/6 holodiastolic rumble and a grade 2/6 systolic murmur were audible at the left lower sternal border. An ECG showed atrial fibrillation with a ventricular rate at 75 beats per minute. Baseline laboratory investigations showed an international normalized ratio level of 1.8 with white cell count of 4960/mm3, erythrocyte sedimentation rate of 9 mm/h, and C-reactive protein level of 4 mg/L. Blood cultures were negative. A transthoracic echocardiogram showed both mechanical tricuspid discs stuck in a fully open position throughout the cardiac cycle (Figure 1A and 1B and …