# A Nearly Missed Case of Mitral Bioprosthetic Paravalvular Leak (PVL)-Related Waring Blender Syndrome Treated With Transcatheter Mitral PVL Closure

## TL;DR

A 72-year-old woman with a bioprosthetic mitral valve developed hemolytic anemia, which was eventually linked to a small valve leak and resolved after repair.

## Contribution

This case highlights a rare but important association between bioprosthetic mitral valve leaks and hemolytic anemia, emphasizing the need for careful echocardiographic evaluation.

## Key findings

- A small paravalvular leak in a bioprosthetic mitral valve was identified as the cause of hemolytic anemia.
- Repair of the leak with glue resolved the patient's hemolytic anemia and improved her symptoms.
- Initial diagnostic tests and imaging failed to detect the leak, underscoring the importance of re-evaluation.

## Abstract

A 72-year-old woman with recently diagnosed non-small cell lung cancer, who underwent cardiac bypass and bioprosthetic mitral valve replacement presented to our cancer center with lightheadedness, severe fatigue, and shortness of breath. Initial blood tests showed mild hemolytic anemia. The patient also complained of occasional bright red bleeding per rectum. Esophagogastroduodenoscopy and colonoscopy did not reveal an acute source of bleeding. An initial transesophageal echocardiogram did not show significant valvular or paravalvular abnormalities. Meanwhile, the patient's hemolytic anemia worsened. She received eight units of packed red blood cell transfusions. Schematic workup for hemolytic anemia revealed negative Coomb’s test, positive urine hemosiderin, normal ADAMTS13 activity, and absent splenomegaly. A relook of the patient's transesophageal echocardiogram (TEE) showed a small paravalvular leak of the bioprosthetic mitral valve. The patient was referred to a tertiary center, and repair of the perivalvular leak with glue resolved her hemolytic anemia, subsequently improving the lab values, symptoms, and quality of life. This case highlights the schematic workup of hemolytic anemia and also the importance of recognizing the association between hemolytic anemia and valvular abnormalities.