LAUSR

A 62-year-old man with a previous history of mitral and aortic valve (St. Jude Medical Valve no 27 and 23, respectively) replacement (22 years ago) and percutaneous closure of paravalvular leaks with three Amplatzer Muscular VSD Occluders devices no 8 (7 years ago) was admitted in our institution due to aggravating dyspnea, ascites, and lower extremity edema. His physical examination revealed grade III/VI holosystolic murmur at right sternal border and rightsided S3. ECG showed AF rhythm and non-specific ST-T changes. TEE (Fig. 1a, online supplementary videos 1–3) and fluoroscopy (Fig. 1b, online supplementary video 4) were performed for further evaluation of mechanical valve function. In transesophageal echocardiography, there were three devices around MV prosthesis in the anterolateral and posteromedial sides of the sewing ring with restricted motion of MV prosthesis medial leaflet. As there were no other spaceoccupying lesions such as thrombus or pannus ingrowth in the field of valve motion, we considered device interference with prosthesis leaflet motion as the main responsible cause. The hindering of the anteromedial device with the aforementioned leaflet is depicted in 2D and 3D images (Fig. 1a, online supplementary videos 1–2). Hemodynamic study of the mitral prosthesis was as following: mean pressure gradient = 9 mmHg, PHT = 150 msec, peak E velocity = 2.1 m/ sec, Doppler velocity index (DVI) = 4.9 and effective orifice area = 1.12 cm2. The measured systolic pulmonary artery pressure was 65 mmHg. In 3D color study, there was significant residual PVL from the anterior side of sewing ring (Supplementary video 3). After the diagnosis, the heart team advised surgery since the patient was highly symptomatic. Following surgical or percutaneous valve replacement, paravalvular leakage is a common complication. It has been reported in 7–17% of patients following MV replacement [1]. Percutaneous transcatheter closure of significant PVLs has been introduced as a substitute to surgical repair, especially in high-risk patients [2]. There are several complications regarding this procedure; including device embolization, wire entrapment during the procedure, aortic dissection, cardiac perforation, and valve interference [3]. Our patient had no regular follow-up during the past 7 years; therefore, there was no available data regarding the progress of PVL. As we had no documented medical records, we assumed that valve interference and notable residual PVL had occurred during the previous procedure; which were missed. The findings during surgery, somehow, confirmed this theory. Since the PVL closure procedure was not performed in our center, and the patient had no available documents regarding the intra-procedural echocardiography, and