Excerpt

An 86-year-old woman was admitted for dyspnea on effort. She had previously undergone double valve replacement (DVR) at 57 years of age because of rheumatic valvular heart disease and re-do DVR at age 69 years. Her hemoglobin level was low (6.6 g/dl) and lactate dehydrogenase level was elevated (1692 IU/l). The 12-lead electrocardiogram showed atrial fibrillation. The chest radiograph revealed a 77% cardio-thoracic ratio. Transthoracic echocardiography (TTE) could not detect any paravalvular leakages (PVLs) because of the acoustic shadow of the mitral prosthesis (Fig. 1a, b). Although transesophageal echocardiography (TEE) could detect mitral regurgitation, we originally thought she had transvalvular leakage, which had seemed to be inside the mitral annulus (Fig. 1c, d). We found that a down-sized 25-mm St. Jude Medical (SJM) mechanical prosthesis had been inserted instead of a 27-mm Björk-Shiley (BS) mechanical prosthesis. The previous sewing cuff of the 27-mm BS mechanical prosthesis remained, and the 25-mm SJM mechanical prosthesis had been inserted inside it (Fig. 1e). Three-dimensional color-Doppler TEE finally detected PVLs between the sewing cuffs, which can cause hemolytic anemia and heart failure (Fig. 1f–h). Her condition was difficult to treat because of old age and frailty; she has been followed up with monthly blood transfusions.

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