title: New-Onset Hemolytic Anemia after Percutaneous Paravalvular Leak Closure.
abstract: Despite being usually clinically silent, paravalvular leak can present with congestive heart failure (CHF) or haemolytic anemia. Here, the case is reported of a paravalvular leak presenting with CHF, complicated by new-onset severe hemolytic anemia after percutaneous closure with a large ventricular septal duct (VSD) occlude device.
  
  
  
  A 57-year-old patient presented with infectious endocarditis of a native mitral valve with major mitral regurgitation and was submitted for mitral valvuloplasty. However, one month later failure of the valvuloplasty forced the need for mechanical prosthetic valve implantation. Early endocarditis of the mechanical valve with CHF was noted two months later and led to mechanical valve substitution. One year later the patient presented with a major paravalvular leak and CHF recurrence. Hence, percutaneous paravalvular leak closure was proposed.
  
  
  
  A 16-mm VSD occluder was used, and clinical and echocardiography success was noticed. However, new-onset hemolytic anemia with acute kidney injury forced surgical re-intervention, with the successful implantation of a third mechanical valve.
  
  
  
  Usually, percutaneous paravalvular leak closure is a safe and successful method to treat high-risk surgical patients. However, hemolytic anemia may develop after a technically successful procedure, forcing surgical intervention. Dedicated devices are needed to overcome this important safety issue. Video 1: Periprocedural acquisition of 3-D transesophageal echocardiography showing two AVP II in the left atrium after unsuccessful deployment. Video 2: Periprocedural imaging of a muscular ventricular septal duct (mVSD) occluder (16 mm), with successful closure of the paravalvular leak.
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal. Electronic correspondence: lmmorais88@gmail.com.
authors.forename: Luís
authors.initials: L
authors.lastname: Almeida-Morais
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: António
authors.initials: A
authors.lastname: Fiarresga
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: Duarte
authors.initials: D
authors.lastname: Cacela
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: Lídia
authors.initials: L
authors.lastname: de Sousa
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: Ana
authors.initials: A
authors.lastname: Galrinho
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: Rui
authors.initials: R
authors.lastname: Rodrigues
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: Lurdes
authors.initials: L
authors.lastname: Ferreira
authors.affiliation: Cardiology Department, Centro Hospitalar de Lisboa Central, EPE Hospital de Santa Marta, Lisbon, Portugal.
authors.forename: Rui
authors.initials: R
authors.lastname: Ferreira
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D000743:Anemia, Hemolytic / Q000209:etiology*; D017548:Echocardiography, Transesophageal; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications; D055989:Septal Occluder Device / Q000009:adverse effects*