# Challenges in Diagnosing Severe Mitral Paravalvular Leaks: A Case Report

## TL;DR

A case report highlights the difficulty in diagnosing severe mitral paravalvular leaks using standard echocardiography, emphasizing the need for transesophageal echocardiography.

## Contribution

The paper presents a case where TTE failed to detect a severe leak, demonstrating the importance of TEE in such scenarios.

## Key findings

- Transthoracic echocardiography failed to detect a severe mitral paravalvular leak.
- Transesophageal echocardiography revealed extensive mechanical valve dehiscence.
- Delayed diagnosis could have been fatal, highlighting the need for early TEE in similar cases.

## Abstract

Symptomatic mitral paravalvular leaks (PVL) are a rare but potentially life-threatening complication after prosthetic valve replacement. While transthoracic echocardiography (TTE) is commonly used for diagnosis, it may miss PVL due to acoustic shadowing from prosthetic materials. We report a case of congestive heart failure with hemodynamic instability due to mitral PVL, which was not detected on TTE. Although transesophageal echocardiography (TEE) is the recommended for precise assessment, it was initially deferred in our case due to concerns that sedation and intubation required to perform TEE could worsen hemodynamic status without identification of the underlying cause. However, persistent heart failure and laboratory evidence of hemolysis ultimately prompted TEE, which revealed extensive mechanical valve dehiscence. Given the extent of the lesion, any further diagnostic delay could have been fatal. This case illustrates the diagnostic limitations of TTE and underscores the importance of early TEE in patients with prosthetic valves presenting with unexplained heart failure and hemolytic anemia.