1. Zhongshan Hospital, Fudan University Shanghai Cardiovascular Disease Institut Shanghai Cardiovascular Disease Institute Guan Lihua, Zhou Daxin, Ge Junbo

2. Patient Demographics and Medical History Male, 69 years Male, 69 years Coronary artery angiography: normal Coronary artery angiography: normal Hypertention: Y Hypertention: Y

3. Clinical Presentation Clinical Presentation Recurrent chest oppression and tachypnea for 29 years, aggravate 3 years 1980s diagnosised as rheumatic heart diease 17 th, Aug, 1999s, mechanical prosthetic valve replacement of MV and AV 7 th, Sep, 1999s, pacemaker implantation because of AF complicated with long pause Recurrent edema of lower limbs 1year

4. Physical examination BP 140/80mmHg ， HR 82bpm, AF Engorgement of Jugular vein ， enlarged dullness of heart, L2-3 III SM, L3-4 DM, R2-3 DM Moist rales of bilateral lungs Slight edema of both lower limbs.

5. Doppler Ultrasound LV59mm 14 th, Sep, 1999s, enlarged LA 、 LV 、 RA, LA49*59mm ， LV59mm ， RA43mm 。 LVEF62% LV55mm 12 th, Oct, 2006s, stenosis and medium-severe perivalvular leakage of aotic mechanical valve. LA42mm ， LV55mm ， RA52mm. PAsP51mmHg. LV61mm 19 th, Oct, 2009s ， medium-severe perivalvular leakage of aotic mechanical valve between right coronary sinus and no-coronary sinus. PAsP69mmHg with medium regurgitation of TV ， LA48mm ， LV61mm, RA39mm ， enlarged RV ， LVEF58% 。

8. angiography Perivalvular leakage ø6mm*8mm, severe regurgitation 14mm blockage

20. Doppler Ultrasound Slight remanent aortic perivalvular leakage PAsP 40mmHg

22. thanks thanks