Discussion
Paravalvular leak has been demonstrated 2-10% in aortic prosthetic implantation and 7-17% in mitral position, respectively{1}. While majority of PVLs is subclinical, approximate 1-5% PVL patients can develop serious clinical consequences, such as severe heart failure, as described in our case{2}. Though given available experiences and guidelines to assess and manage PVL, diagnosis and differential diagnosis of PVL may not be effortless like we imaged.
In our case, patient was once mistaken as coronary artery-left ventricular fistula, probably owing to limitation of acoustic shadowing, which could preclude visualization of aortic prosthetic components, resulting in misidentification of abnormal color doppler signal, and underestimate severity of regurgitation. Coronary artery fistula is an anomalous connection between coronary artery and cardiac chamber or great vessel, accounts for 0.2%-0.4% of congenital heart disease{3}. Majority of coronary fistula opens to the right heart, very rare in the left ventricular. 2D echocardiography shows dilated and tortuous coronary artery, and associated enlarged feeding artery, sometimes appearing the origin or course of the fistula vessel{4-6}. Color Doppler helps in detection of the entrance and termination site of drainage, characterized by continuous shunt both in systolic and diastolic period{4}. PVL, unlike, usually appears as abnormal jet flow outside prosthetic valve frame, no course of drainage. TEE can display heart structure more clearly than TTE in real time, help quantitatively evaluate heart function and heart structure, and be simpler, cheaper and less time-consuming than cardiac angiography. In addition, multi-modality imaging, including combination of TTE, TEE and cardiac angiography, may be needed to confirm and assess coronary fistula considering the complexity of diagnosis{1,2}. As in this case, TEE descriptions promote suspicion of PVL, and cardiac angiography confirmed it, stressing the utilization of multi-modality in PVL diagnosis.
Previously, clinically significant PVLs could be only corrected by reoperation, whereas, along with increased mortality closely related to reoperation. In recent two decades, transcatheter closure has evolved as available option for PVL patients, especially for those who are at high surgical risk and have suitable anatomic features for transcatheter closure{1}. In the literature, a large amount of PVL cases have been successfully closed with various occlude devices, despite that no device has been approved for PVL occlusion by FDA{1,2,7,8}. Available devices include the Amplatzer family of occluders/plugs (St Jude Medical, St Paul, MN, USA), Amplatzer septal occluder (ASO), Amplatzer muscular VSD occluder (mVSD), Amplatzer duct occluder (ADO), and Amplatzer vascular plugs (AVP II and III). On the other hand, successful closure require experienced interventional cardiologists to be familiar to complex catheter techniques and have facility to perform. Our present report is a successful case of repair of aortic paravalvular leakage with one kind of domestic Plug device.