A 53-year-old man with atrial fibrillation underwent mitral and aortic mechanical valve replacements with St. Jude bileaflet tilting disk valves due to endocarditis in the setting of underlying rheumatic heart disease with moderate mitral stenosis. He was discharged on warfarin with an INR goal of 2.5-3.5. Read more about this medical malpractice case and the "Three P" Analysis.