How should i treat recurrent severe paravalvular leakage after successful interventional closure of a symptomatic paravalvular leak with four plug devices following complicated bioprosthetic aortic valve replacement? the importance of closely monitoring patients after interventional procedures

BACKGROUND: A few weeks after complicated redo bioprosthetic aortic valve replacement for infective endocarditis of a bioprosthesis, a 74-year-old male patient developed severe and symptomatic aortic valve regurgitation due to a large paravalvular leak (PVL) and underwent successful interventional closure of the PVL with sequential implantation of four AMPLATZER Vascular Plug III devices. Despite the initial success of the procedure, with a significant decrease in AR (grade II) and clinical stabilisation of the patient, he was re-admitted to hospital six months later due to advanced signs of heart failure. 3D-TOE again showed severe paravalvular AR next to the implanted plugs. INVESTIGATION: Transthoracic echocardiography, 3D-TOE, laboratory tests, cardiac catheterisation including aortography. DIAGNOSIS: New severe PVL after interventional PVL closure after complicated bioprosthetic aortic valve replacement. MANAGEMENT: Interventional PVL closure.