A decade-long device–valve interaction: severe aortic regurgitation after residual ventricular septal defect closure

A NTI1008"49-year-old woman underwent tetralogy of Fallot repair at age 16, including closure of a 25 mm intracristal ventricular septal defect (VSD) and right ventricular outflow tract reconstruction. Sixteen years later, a postoperative residual VSD was closed transcatheterly. Eleven years after device implantation, echocardiography showed mild-to-moderate aortic regurgitation (AR), which progressed to severe over 2 years, while the ascending aortic diameter increased from 38 to 45 mm despite 6-month surveillance. At the current admission, three-dimensional transoesophageal echocardiography showed the occluder impinging on the non-coronary and right coronary cusps at the commissure, restricting cusp motion and producing severe AR on colour Doppler (Panel A). Computed tomography confirmed protrusion into the aortic valve complex (Panel B). At surgery, both cusps were markedly thickened and firmly adherent to the occluder at the commissure (Panel C). The protruding portion of the device and adherent cusp tissue were excised (Panel D), followed by mechanical aortic valve replacement (Panel E). Recovery was uneventful, with normal prosthetic function at 1 month.