From the heart to the kidney: A case report of Wunderlich syndrome following structural valve intervention

Wunderlich syndrome (WS) represents spontaneous, nontraumatic renal hemorrhage, a rare yet potentially life-threatening condition most often associated with renal neoplasms, vascular malformations, or coagulopathies. This report describes WS as an uncommon complication following a percutaneous paravalvular leak (PVL) closure attempt after transcatheter aortic valve implantation (TAVI), in a patient receiving procedural anticoagulation, without renal manipulation or prior renal pathology. A 78-year-old hypertensive man, ex-smoker, underwent transfemoral TAVI with an Evolut™ R 34 mm prosthesis for severe symptomatic aortic stenosis. Postprocedural echocardiography revealed moderate-to-severe PVL. A percutaneous closure attempt with 2 Amplatzer™ Vascular Plugs under unfractionated heparinization (maximum ACT 250 s; total dose 8000 IU) failed to resolve the leak. Eighteen hours later, he developed right flank pain. CT (arterial and venous phases; 120 kVp; 1.25 mm slices) revealed a 9.4 × 6.8 cm right perirenal hematoma (52 HU) with retroperitoneal extension and no active extravasation. Despite initial stability, he became hypotensive (88/54 mmHg) with hemoglobin drop (9.0 → 6.0 g/dL). Renal arteriography confirmed no active bleeding. He received 3 units of PRBCs, Hb stabilized at 9.5 g/dL, and creatinine peaked at 1.4 mg/dL before normalization. Conservative management led to full recovery. Follow-up imaging (ultrasound at 6 weeks, CT and angiotomography at 3 months) confirmed hematoma resolution, preserved renal function, and normal blood pressure. This case underscores WS as a rare and atypical complication of structural cardiac intervention under procedural anticoagulation. Vigilant monitoring, multimodal imaging, and multidisciplinary collaboration are vital for successful conservative management and for excluding occult renal lesions.