A rocking aortic valve refers to an abnormal motion of the entire prosthetic valve sewing ring relative to the native annulus. It is a classic sign of prosthetic valve dehiscence, most commonly caused by prosthetic valve endocarditis with annular tissue destruction. TEE may also show peri-annular abscess, severe paravalvular regurgitation, vegetation, and fistula formation.

                       A rocking prosthetic valve indicates partial or complete loss of fixation of the prosthesis (dehiscence) and is always an abnormal finding. The motion involves the whole prosthesis, not just the leaflets or occluders. It is most commonly caused by prosthetic valve endocarditis, suture disruption, annular tissue destruction, and at times technical failure of valve implantation.

                       The combination of rocking prosthetic valve and severe paravalvular regurgitation is highly suggestive of prosthetic valve endocarditis with peri annular extension of the infection. Severe paravalvular regurgitation occurs when blood leaks around the prosthesis through the dehisced portion of the annulus.

                         Anticoagulation and follow-up is generally not the appropriate management for a rocking prosthetic valve as it does not treat valve dehiscence and may even increase the bleeding risk if surgery is required. Appropriate management is urgent evaluation by a cardiac surgery team, blood culture and intravenous antibiotics. If infective endocarditis is suspected, early or urgent surgical repair or valve replacement is indicated.

Hence, the correct answer is option ‘d’.

Reference:

1. Nair A, Sajeev CG, Muneer K. Prosthetic aortic valve dehiscence: a "rocking" catastrophe. J Echocardiogr 2016;14:171-2.