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.