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( A) Transesophageal echocardiography showing a blockage of one of the leaflets of the mitral valve prosthesis with increased transprosthetic gradients (maximal gradient 24 mmHg, mean gradient 10 mmHg and velocity V max 2.5 m/s). ( B) Coronary angiography confirmed the blockage of one of the leaflets of the 23-year-old 31-mm diameter mechanical bileaflet mitral valve prosthesis. ( C) Intraoperative findings: the upper leaflet of the mechanical prosthesis was almost completely covered by a huge pannus formation, and the effective mitral orifice was significantly narrowed. ( D) After resection of the attached pannus tissue, both leaflets of the mechanical prosthesis were visible and moveable.