Figure 2 and Clip S4 Transoesophageal long-axis view of the aortic valve. Visualization of a long vegetation (A) (larger axis: 26 mm) on the atrial side of the mitral valve, with insertion on the aortic ring (B) and reduced. It was still possible to visualize the morphological distortion of the aortic cusps, its eccentric closure (bicuspid) as well as a filamentar image in the left ventricular outflow tract (LVOT) (C), probably in concordance with other vegetation (C). There was a large aortic regurgitation jet, anteriorly directed to the anterior leaflet of the mitral valve. In relation with mitral valve involvement by the vegetation, but equally as possible injury of the aortic jet, there was a perforation of the anterior leaflet with an important regurgitation jet. ECG recording was notable for a large atrio-ventricular conduction delay.