Improvement of acute hemolysis after mechanical valve replacement by prosthesis rotation without redo replacement.

UNLABELLED: A1-year-old female with a partial atrioventricular septal defect and a borderline left ventricular size underwent a left-sided atrioventricular valve plasty at four months. Due to persistent regurgitation, a reoperation was performed at one year for left-sided atrioventricular valve replacement. The valve was implanted in an anti-anatomical position and the side of the posterior wall translocated toward the left atrium because of a narrow annulus. Postoperative course was initially good, but lactate dehydrogenase levels significantly rose to 2262 U/L by postoperative day 14. Echocardiography revealed mild paravalvular leakage on the septal and left atrial sides. A greater regurgitant jet was observed from the posterior left atrial hinge compared to the septal side. Reoperation was performed for mechanical valve adjustment on postoperative day 17. The left atrial wall side, suspected of paravalvular leakage, was broadly reinforced with felt strips. Intraoperative transesophageal echocardiography still showed significant regurgitation from the left atrial hinge. The mechanical valve was rotated 40 degrees counterclockwise. Post-rotation, the regurgitant jet significantly decreased. Lactate dehydrogenase normalized, and resolution of transvalvular leakage and associated hemolysis was confirmed. This case highlights the complexity of mechanical valve implantation in challenging anatomies and the importance of addressing subtle leaks.

LEARNING OBJECTIVE: A1-year-old female with a partial atrioventricular septal defect and borderline left ventricular size underwent a left-sided atrioventricular valve replacement. Postoperatively, she developed hemolysis, which was suspected to be caused by transvalvular leakage. A reoperation involving valve rotation and paravalvular leakage repair resolved the hemolysis. It is possible that the specific structure of the mechanical valve contributed to the hemolysis, warranting further investigation.