Perpendicular and turbulent flow after aortic valve replacement: paravalvular or transvalvular leakage? – a case report

BACKGROUND: Perpendicular transvalvular leakage (TVL) is occasionally observed after aortic valve replacement (AVR) in biological valves with a stent post, often originating from the base of the stent post. However, an observed perpendicular jet flow is not always a TVL. In rare cases, paravalvular leakages (PVLs) can be perpendicular and are present behind a TVL. In the present case, both PVL and TVL existed simultaneously as unusual perpendicular jet flows that originated from sites in close proximity to the stent post. CASE PRESENTATION: A 73-year-old man underwent AVR with a biological valve in the supra-annular position using the non-everting mattress suture technique with pledgets. After weaning from cardiopulmonary bypass (CPB), transesophageal echocardiography (TEE) revealed an unfamiliar perpendicular turbulent flow, similar to reported TVL, originating from the anterior stent post. Further TEE examination revealed a PVL had originated from the site between the sewing ring at the anterior stent post and native annulus attached to a pledget. The space between the sewing ring and annular retained native portion caused the perpendicular turbulent jet. Consequently, two types of perpendicular turbulent flows, TVL and PVL, existed adjacent to each other. After reinstitution of CPB, inspection of the prosthesis itself indicated it to be normal, but there was a region adjacent to the anterior stent post near the right coronary ostium where the tip of the curved Pean forceps entered between the sewing ring and the native annulus. The region was consistent with TEE findings. AVR was performed with the same prosthesis again. After weaning from CPB, immediate TEE revealed that the unusual perpendicular turbulent flows had disappeared and only a few small TVLs were observed. Regarding the disappearance of TVL, we considered that the fabric region of the prosthetic valve was covered with cellular elements to prevent the leak, as it was already used in AVR once and soaked in blood. CONCLUSIONS: Perpendicular turbulent flow raises the possibility of both TVL and PVL in the case of AVR with stented bovine pericardial valves. For a differential diagnosis of TVL or PVL, it is important to know the surgical procedures and valve morphology.