Case presentation
A 72-year-old man was referred to our emergency room due to exertional dyspnea for 3 years, aggravation for 1 week. He had 3 years history of valvular heart disease, and herpes zoster of right leg 2 month back, home medication included bisoprolol, Atorvastatin and acyclovir. Abnormal elevated cardiac enzymes, including troponin level trending up to 52.5 (0–14 ng/L) and brain natriuretic peptide up to 4321(8–21 mg/dL), suggested presence of congestive heart failure. Transthoracic echocardiography (TTE) had proven severe aortic valve regurgitation and mild aortic valve stenosis, with significantly dilated left ventricular of 81mm, and impaired left ventricular eject fraction of 39%. Then the patient was admitted to cardiovascular surgery unit. On admission, initial vital signs showed a body temperature of 36.5℃, blood pressure of 111/75 mm Hg, respiration rate of 20 breaths/min, and heart rate of 68 beats per min. The patient received aortic valve replacement under cardiopulmonary bypass one week after admission, intraoperative TEE showed no paravalvular leak, postoperatively, was routinely transferred into intensive care unit.
During ICU, the patient showed continuous low cardiac output syndrome, even with large dose of cardiotonic. Postoperative TTE revealed dilated left ventricular of 73mm, and significantly reduced eject fraction of 30%. Whereas, in the apical 5-chamber view, TTE detected dubious coronary flow with velocity of 2.8 m/s in the left ventricular outflow tract (LVOT), which suspected coronary-left ventricular fistula, which neither monitored in preoperative TTE nor intraoperative TEE. Therefore, we performed a second TEE to him 3 days post-surgery, noticing a jet regurgitation in long axis view of aortic valve, which started outside prosthetic frame into LVOT, with high velocity of 4.41m/s and vena contract width of 4.7mm (Figure 1a-1b). Short axis view of aortic valve also revealed the regurgitation was paravalvular, outside the edge of sewing ring (Figure 1c-1d). PVL was highly suspectable, then subsequent ascending aortic angiography confirmed it (Figure 2). PVL diameter was calculated by angiography, showing approximate 3mm closed to aortic root. Afterwards, leak was passed by a hydrophilic terumo 0.32 inch guide wire and 5 F delivery catheter was placed into left ventricle, transcatheter occlusion was successfully made to intervene by preforming a 10mm Vascular Plug device (Starway Medical Technology Inc., Cardi-O-Fix Plug Occluder )(Figure 3a). After device was in place, second aortic root angiography revealed no sign of PVL during opening of aortic side, neither of coronary obstruction (Figure 3b). 8 days after closure, TTE showed reduced left ventricular of 50mm, left ventricular motion synchrony, slightly increased EF of 38%, as well as no observation of PVL. The patient had been discharged from hospital 26 day post-surgery, no signs of recurrence have been detected in 2 months of follow-up.