PMC8081127_01
Two-dimensional transesophageal echocardiography image: Transgastric long axis view with continuous wave Doppler showing pressure half time of aortic regurgitation jet
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F1
On the day of surgery after standard anesthesia induction, intubation, and maintenance, TEE was done with real-time three-dimensional enabled probe (X7-2t with ie33, Philips Ultrasound, Bothell, WA, USA), which revealed a severely calcified bicuspid aortic valve with severe AS, severe aortic regurgitation [Figure 1 and Video 1] with dilated left ventricle with severe left ventricular (LV) dysfunction with an ejection fraction of 18%.
(a) Two-dimensional transesophageal echocardiography image: Modified Mid-esophageal aortic valve short axis view with x-plane view 90  showing mass in LAA (b) Gross specimen of thrombus after excision
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F2
The mass was sessile with irregular borders, homogenous echogenicity measuring 2.2 x 1.4 cm [Figure 2a and Video 2]. Left atriotomy was done and the mass, which was identified grossly as thrombus, was removed and internal plication of LAA done [Figure 2b].
Two-dimensional transesophageal echocardiography image: Transgastric long axis view with continuous wave doppler showing high mean systolic pressure gradient of 64 mmHg across native bicuspid valve (upper panel) and reduced mean systolic pressure gradient of 4 mmHg across replaced mechanical valve (lower panel)
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F3
Postoperative TEE showed an improvement in ejection fraction to 43% and a reduction in mean systolic gradient across aortic valve from 64 to 4 mmHg [Figure 3 and Video 3].