Mitral leaflet perforations after surgical aortic valve replacement may be iatrogenic or due to endocarditis. We present a 20-year-old female who underwent surgical mechanical aortic valve replacement 8 months prior to this presentation for bicuspid severe aortic valve stenosis. She presented with acute decompensated heart failure with dyspnea and New York Heart Association (NYHA) functional class of III-IV. Transthoracic (TTE) and transesophageal echocardiography (TEE) demonstrated severe mitral regurgitation (MR) through an anterior mitral leaflet perforation. The patient refused surgical repair and percutaneous closure of the perforation was decided and performed using both antegrade and retrograde approaches. In this report, we emphasize the details and challenges of the procedure.

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The recommended anticoagulation regimen for continuous-flow left ventricular assist device (LVAD) systems is warfarin and aspirin with a targeted international normalized ratio (INR) of 2.0-3.0. Our patient is a 58-year-old male who underwent surgical HeartMate III continuous-flow LVAD implantation 3 months ago outside the country. The patient mistakenly stopped taking warfarin for 1 month prior to presenting to our center for a routine visit. Luckily, the patient was doing very well without any complication despite the fact that his INR was 1.0.