PMC8320548_01
Transesophageal echocardiography (TEE) midesophageal aortic valve long-axis view showing aortic valve endocarditis with perforated cusp and severe aortic regurgitation.
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On admission, transthoracic echocardiography (TTE) and a subsequent TEE revealed severe aortic regurgitation (AR) from a flail non-coronary cusp (Classification of regurgitation according to American Society of Echocardiography), with vegetations on all three cusps (Figure 1; Clips 1 and 2 in Supplemental Material).   Whereas tricuspid and mitral valve (MV) were both without apparent vegetations.
(a) Initial transesophageal echocardiography (TEE) zoomed midesophageal 4-chamber (ME-4CH) view showing moderate mitral regurgitation (MR) (zoomed recording resized to match scale of Panel b). (b) Initial intraoperative TEE vena contracta (VC) measurement of severe MR in ME-4CH view before surgery. (c): Intraoperative TEE after aortic valve replacement (AVR) and cardiopulmonary bypass (CPB). (d): Postoperative transthoracic echocardiography (TTE) apical 4-chamber view with mild MR (4 months after AVR).. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.
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Pre-existing severe TR was confirmed, and severe mitral regurgitation (MR) was noted in TEE (Figure 2(a); Clip 3 in Supplemental Material). TTE exam, the initially performed intraoperative TEE revealed severe-grade MR (vena contracta (VC), 8 mm; PISA method quantification: effective regurgitant orifice area (EROA), 0.55 cm2; regurgitant volume, 63 mL, all measured in midesophageal long axis view), with a dense and notching regurgitant jet (Figures 2(b) and 3; Clip 5 in Supplemental Material).   Left cavities were dilated (LVEDD, 62 mm; MV diameter, 38 mm ME commissural view, 27 mm ME LAX view) but left ventricular function was preserved (Clip 6 in Supplemental Material). The mechanism of MR appeared mixed, as there was malcoaptation (Carpentier's Classification IIIb) but also some thickening of both leaflets. TEE on partial CPB during reperfusion as well as after complete weaning from CPB showed sustained improvement of the formerly severe- to mild-grade MR (Figure 2; Clip 7 in Supplemental Material), this classification also held true when the MV was carefully challenged with elevated afterload by norepinephrine (100 mm Hg systolic, 56 mm Hg diastolic, and 70 mm Hg mean arterial pressure, heart rate 89 per minute). Two postoperative follow-up echocardiograms confirmed the presence of a merely mild MR (one 6 days and the other exam 4 months after surgery, Figure 2, each with normal blood pressures and heart rates).