EuroIntervention 2017;13:888-892 DOI: 10.4244/EIJ-D-15-00001 888 © Europa Digital & Publishing 2017. All rights reserved. HOW SHOULD I TREAT? *Corresponding author: Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstr. 79, D-67063 Ludwigshafen, Germany. E-mail: wernern@klilu.de PRESENTATION OF THE CASE In July 2014, a 74-year-old male patient in good general condi- tion underwent a surgical aortic valve replacement (SAVR) with xenograft, mitral and tricuspid valve reconstruction due to severe symptomatic aortic valve regurgitation due to prolapse of the right and left coronary cusp, moderate to severe secondary mitral valve regurgitation and severe tricuspid valve regurgitation. Severely reduced ejection fraction was present on echocardiography before the procedure. After an uneventful early postoperative period with regular discharge, the patient was re-admitted to hospital three weeks after the procedure for symptoms of stroke. Cerebral MRI showed multiple cerebral ischaemic lesions in different areas of the brain, suggesting a cardioembolic origin. Acute endocarditis of the reconstructed mitral valve and the prosthetic aortic valve was confirmed by transoesophageal echocardiography (TOE) and detection of coagulase-negative staphylococcus in all blood cul- tures. Four weeks after the first surgical valve replacement, the patient underwent re-operation including implantation of a 27 mm xenograft in the aortic valve position and a Hancock ® II prosthe- sis (xenograft, 33 mm) (Medtronic, Minneapolis, MN, USA) in the mitral valve position. During the operation, a paravalvular leak next to the aortic bioprosthesis was observed by the surgeon but was left untreated due to a complicated situs. After a good initial recovery, the patient developed progressive signs of congestive heart failure a few weeks after re-operation due to severe paraval- vular aortic valve regurgitation. 3D-TOE showed a paravalvular defect at 7 o’clock (according to the location diagram of Ruiz et al 1 ) with an orifice diameter of approximately 13×8 mm (Figure 1, CASE SUMMARY BACKGROUND: A few weeks after complicated redo bio- prosthetic 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 implanta- tion 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. KEYWORDS: catheter-based closure, interventional closure, paravalvular leak, plug 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 Nicolas Werner 1 *, MD; Caroline Kilkowski 1 , MD; Boris Fraiture 1 , MD; Uwe Zeymer 1 , MD; Ralf Zahn 1 , MD 1. Herzzentrum Ludwigshafen, Ludwigshafen, Germany Invited experts: Sameer Gafoor 2,3 , MD; Gianfranco Butera 4 , MD, PhD 2. Swedish Heart and Vascular, Seattle, WA, USA; 3. CardioVascular Center Frankfurt, Frankfurt, Germany; 4. IRCCS Policlinico San Donato, Pediatric and Adult Congenital Cardiology, San Donato Milanese, Italy The concluding section “How did I treat?” together with the complete references are published online at: http://www.pcronline.com/eurointervention/122nd_issue/130