Challenges in Diagnosing Severe Mitral Paravalvular Leaks: A Case Report

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.