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.