35 Percutaneous treatment of refractory heart failure secondary to early post-operative paraprosthetic aortic regurgitation

Introduction Paravalvular Leak (PVL) is a recognised but rare complication of aortic valve (AV) surgery; leaks may range from mild and subclinical to severe resulting in fulminant cardiac failure. Echocardiography is the diagnostic modality of choice; however, identifying a PVL can be quite challenging. In the absence of confirmatory echocardiography, establishing PVL as a cause of refractory heart failure in the early post-operative period following surgery may require a high index of clinical suspicion and the use of multi-modality imaging to aid diagnosis and plan therapeutic options. Methods A 75-year-old gentleman with a heart murmur and angina underwent transthoracic echocardiography (TTE) and coronary angiography. TTE showed good left ventricular function and moderate aortic stenosis (AS) with a peak velocity of 3.1 m/s. Coronary angiography demonstrated severe coronary artery disease (CAD) affecting the left main stem. He was managed with coronary artery bypass graft and concomitant aortic valve replacement (Edwards Intuity Elite) surgery. Shortly after discharge, he was admitted with symptoms of heart failure (NYHA 3) and atrial flutter (2:1 AV block). Chest X-ray revealed large bilateral pleural effusions and TTE showed systolic impairment (Ejection fraction (EF) 40%). There were no obvious concerns identified with the aortic valve prosthesis initially. Due to the refractory nature of his heart failure requiring thoracentesis, repeat TTE imaging was performed suggesting highly eccentric aortic regurgitation. Transoesophageal echocardiography (TOE) confirmed at least moderate paravalvular regurgitation with a highly eccentric regurgitant jet laterally, with no signs of vegetation or thrombus. Gated Cardiac CT showed right and left lateral paravalvular leaks, with good apposition with the aortic wall anteriorly and posteriorly. The valve leaflets appeared thin and freely mobile, with good closure. Results In view of his refractory symptoms being likely secondary to paravalvular regurgitation, he was managed with percutaneous paravalvular leak (PVL) device closure (figures 1 and 2), under TOE guidance, requiring three occlusion plugs and resulting in significant reduction in the degree of regurgitation. Three months later, the patient has shown marked clinical improvement, and minimal residual pleural effusions oedema on Chest x-ray. TTE shows no residual paravalvular leak. However, the left ventricular systolic function remains severely impaired (EF of 30–35%). He remains under specialist follow-up for the management of his heart failure and atrial flutter. Conclusion Early PVL is a recognised but uncommon complication following AV surgery. PVL may not be clinically obvious and require a high index of clinical suspicion in patients with HF post valve surgery/ intervention. When symptomatic, PVL often presents with HF due to volume overload in up to 90% of patients, and progression can only be addressed by closing the defect. Echocardiography plays an essential role in diagnosing PVL. Identification is a challenge, especially in differentiating PVL from transvalvular regurgitation. Furthermore, the relatively small LV outflow tract causes overstimulation of colour flow Doppler and the acoustic shadowing caused by the sewing ring often obscures the view. Additional imaging techniques, including 3D-TOE and ECG-gated CT, can provide further information. Percutaneous PVL closure, although technically challenging, has the ability to improve symptoms and cardiac function in high-risk patients who are refractory to medical therapy. Conflict of Interest N/A