Symptomatic paravalvular leakage after mechanical aortic valve replacement in a critically ill patient: why not just "plug" the hole?

We report on an 81-year old man with decompensated severe aortic regurgitation due to a large paravalvular leakage of mechanical aortic valve prosthesis. Because of relevant co- morbidities the patient was unable to undergo cardiovascular surgery. Non- invasive imaging allowed exact localization of the leakage and sizing of the defect diameter; therefore, we decided to perform interventional closure of the defect using the Amplatzer Vascular Plug III device. The intervention was guided by transoesophageal echocardiography. Afterwards the patient's medical condition improved continuously. Follow up echocardiography showed stepwise decrease in severity of aortic valve insufficiency. These findings illustrate, first, that echocardiography is extremely helpful to select patients which may benefit from interventional closure of a paravalvular leakage after valve replacement. Secondly, non-invasive imaging is indispensable during such a complex intracardiac procedure to guide the intervention. Thirdly, the TEE findings during follow-up demonstrate nicely that acute implantation of the device is followed by a subsequent 'healing' process (including thrombus/scar formation and endothelialization) which is mainly responsible for successive defect closure.