Author + information
- Rajeev Bhardwaj1
Patient initials or identifier number
Relevant clinical history and physical exam
A 67 years -old female, underwent DVR 2 years back. She was presented with H/O breathlessness class II for 2 months. P regressed to class III for 2 weeks. Orthpnea for 10 days, PND for 7 days, bilateral swelling feet for 4 days.
On examination-BP 136/56, pulse 136/min, respiratory rate 28/min, JVP 10 cm above sternal angle, bilateral pedal edema. echocardiography: LV enlarged with global hypokinesia, EF 38%. Mitral prosthesis normal. Severe paravalvular leak around aortic prosthetic valve.
Relevant test results prior to catheterization
• HB 10.5 gm%
• TLC 6000/ mm3
• Platelet count 1.88 lac/ mm3
• ESR 10mm in 1st hr
• BUN 22mg/dl
• S. creatnine 0.7 mg/dl
• Reticulocyte count 1.5%
• LDH 305 IU( Normal<248)
• Total bilirubin 1.53 mg/dl
• Direct bilirubin 0.56 mg/dl
• Serum haptoglobin 14 mg/dl (Normal 30-200 mg/dl)
Relevant catheterization findings
Aortic root angiography showed severe paravalvular leak aroud the aortic prosthetic valve.
The paravalvular track was crossed with V18 wire, with the support of right Judkins catheter.the catheter was then negotiated into the left ventricle. The wire was the exchanged with Amplatzer .o35 guide wire. a delivery sheath was then negotiated over this wire into the LV.Amplatzer vascular plug II (AVP II)was the introduced through this sheath into the LV. Sheath was withdrawn to deliver distal disk, and then further pulled tp deliver the remaining device of 14 mm size. check angio showed the persistence of leak. Therefore, device was retrieved and the procedure repeated to deliver the 16 mm device. before releasing the device left coronary angiography was done from a radial approach to confirm that device was not obstructing the left main coronary artery. check angio showed the sealing of the defect. the device was released.
Symptomatic paravalvular leak is uncommon but serious complication of prosthetic valve surgery, and most of the cases occur during surgery or hospital stay.
Very few cases presented late after the surgery.
Redo surgery is the treatment of choice but is difficult and is associated with higher mortality.
Device closure is good alternative to surgery, with less complications, but is technically challenging.