Structures on the ventricular side of the prosthetic valve in extremely late mitral paravalvular leak: a case report

BACKGROUND: Mechanisms of paravalvular leak (PVL) after mitral valve replacement have not been fully delineated. Herein, we report a case of structures on the ventricular side of the mitral valve in a patient with an extremely late PVL. CASE SUMMARY: A 68-year-old female underwent aortic and mitral valve replacement with a mechanical valve 29 years ago. She was in good health for 28 years. However, exertional dyspnoea appeared 8 months ago. She was admitted to our hospital for congestive heart failure and haemolytic anaemia. Echocardiography showed severe regurgitation due to PVL of the mitral valve. The fluoroscopy showed that a circular calcification was found below the mitral prosthesis. The operation was performed through a median sternotomy. After the aortic cross-clamp, the aortic mechanical valve was removed. The ventricular side of the mitral valve was inspected with the endoscope through the aortic annulus before manoeuvers were performed in the mitral valve. A gap was seen between the prosthetic valve and annular tissue and subvalvular calcification. A bioprosthetic valve was placed with a modified collar-reinforcement technique using a xenopericardium strip. The postoperative course was uneventful. PVL and haemolysis completely disappeared. DISCUSSION: The ventricular side of the prosthetic valve could be observed before the mitral valve was removed. Not only the protruding circular calcification and displacement of the prosthetic valve to the atrial side but also the loss of adhesion and adhesive nature of the annular tissue played a definitive role in the late PVL occurrence and recurrence after percutaneous or surgical repair.