Case Presentation
The patient was a 51-year-old female with a history of hypertension and
biological aortic valve replacement surgery 21 years ago who was
referred to our hospital for dyspnea. Electrocardiogram revealed sinus
rhythm and incomplete left bundle branch block. Transthoracic
echocardiography demonstrated normal left ventricular (LV) systolic
function and severe LV diastolic dysfunction. Mild LV hypertrophy was
also observed. There was a flail bioprosthetic leaflet due to the
degeneration of aortic bioprosthesis resulting in severe aortic
regurgitation and severe aortic stenosis (Video S1, Video S2, Video S3).
Furthermore, severe posteriorly directed mitral regurgitation was
detected. The patient was admitted for redo aortic valve replacement and
mitral valve surgery, and she was submitted to coronary angiography
before the surgery due to chest discomfort and electrocardiographic
changes. In the catheterization laboratory, she had a blood pressure of
about 160 over 90 mmHg after placing the sheath in the right femoral
artery. Prior to the procedure, the patient gradually developed dyspnea
and severe orthopnea. Her blood pressure rose to 270 over 130 mmHg
(Figure 1), and she had a respiratory rate of 30 per minute, a heart
rate of 120 per minute, and an oxygen saturation of 89 percent in the
room air. Diffuse rales were heard in both lungs. Her situation suddenly
exacerbated, and clinical evidence of FPE was apparent. She was placed
in a semi-setting position, and supplemental oxygen therapy with a mask
was started. Resuscitation equipment was prepared. ECG was obtained, but
it did not show any new changes. Intravenous nitroglycerine and
furosemide were soon administered. Nitroglycerin infusion was started at
a rate of 30 micrograms per minute and the dose doubled every 15 minutes
up to 90 micrograms per minute. She also received three doses of 40
milligrams of furosemide at 20-minute intervals. After about an hour
with the continuation of the vasodilator, loop diuretic therapy, and
respiratory support under hemodynamic monitoring, the patient’s
condition improved clinically, and she was stabilized. Coronary
angiography was performed and showed no significant lesion. Two days
later, she underwent aortic and mitral valve replacement surgery. The
timeline of the events is shown in Table 1.