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.