PMC10292925_01
Left side: ECG before procedure showing atrial fibrillation, narrow QRS, and two premature ventricular contractions; right side: ECG after procedure showing a large QRS with a left bundle branch block.
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F1
Immediately after the procedure, a new left bundle branch block was noted (Figure 1) that motivated a His-ventricular (HV) exploration.
(A) Amplatzer vascular plug and bioprosthesis in vivo. (B) Angiography of initial implantation of Amplatzer vascular plug. (C) Bioprosthesis ex vivo with manual replacement of the Amplatzer vascular plug by the surgeon.
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F2
Plug 4 of 8 mm (Figure 2B), resulting in a significant reduction of regurgitation and resolution of the heart murmur. Post-procedural echocardiography showed a residual paravalvular leak involving 1/5 of the valve perimeter, a calculated valve surface of 1 cm2, and a trans-aortic mean gradient of 14 mmHg. During the surgical procedure, it was found that the Amplatzer had moved from its initial position and was oriented towards the leaflets of the bioprosthesis as shown in Figures 2 A,C.
Transthoracic echocardiography image of the paravalvular leak in short-axis view (A) and apical five-chamber view (B).
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F3
At this time, echocardiography showed mixed aortic disease with aortic stenosis characterised by a surface of 1 cm2, a mean gradient of 23 mmHg, and a significant paravalvular aortic regurgitation involving 1/3 of the valve perimeter (Figure 3).