A 55-YEAR-OLD male patient with increasing dyspnea on exertion and valvular heart disease was referred for surgery. A transthoracic echocardiogram revealed moderate mitral stenosis and mild mitral regurgitation with moderate pulmonary hypertension. In addition, thrombi were identified in the left atrium (LA) and left atrial appendage. In the operating room, transesophageal echocardiography (TEE) confirmed the preoperative findings. A 27-mm internal-diameter, ATS prosthetic valve (ATS Medical Inc, Minneapolis, MN) was placed in the mitral position, and LA and left atrial appendage thrombi were removed.