Acquired Gerbode Defect After TAVR Presenting With Severe Acute Liver and Kidney Injury

BACKGROUND: Acquired Gerbode defects after transcatheter aortic valve replacement (TAVR) are rare and may present atypically, delaying diagnosis. CASE SUMMARY: A 71-year-old man presented 15 days after TAVR with severe acute liver and kidney injury despite preserved ventricular systolic function and normal prosthetic valve function on transthoracic echocardiography. Right heart catheterization revealed elevated filling pressures, an oxygen saturation step-up from the superior vena cava (51%) to the pulmonary artery (79%), and a pulmonary/systemic flow ratio of 2.9. Transesophageal echocardiography identified a high-pressure left ventricular-to-right atrial shunt through the membranous septum. Residual shunting after transcatheter closure caused severe intravascular hemolysis and necessitated surgical salvage. The postoperative course was complicated by multiorgan failure and death. DISCUSSION: This case highlights an atypical presentation of an acquired Gerbode defect. Complementary transesophageal echocardiography and invasive hemodynamic assessment were essential for diagnosis. TAKE-HOME MESSAGE: Occult intracardiac shunting should be considered after TAVR when severe end-organ dysfunction is discordant with reassuring transthoracic echocardiographic findings.