PMC5804590_01
a Preoperative transesophageal echocardiography. Severe calcification was observed in all leaflets and aortic annulus (arrowheads). b Preoperative transesophageal echocardiography. The left coronary ostium was intact; there was no significant stenosis (dotted circle)
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Fig1
TTE, TEE showed severe calcification of the aortic leaflets and annulus (Fig. 1a). TEE revealed the left coronary ostium intact (Fig. 1b).
Preoperative coronary angiography. Left coronary ostium did not show significant stenosis (dotted circle)
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Fig2
Similarly, preoperative coronary angiography did not reveal significant stenosis (Fig. 2).  
Intraoperative transesophageal echocardiography. Left, a high-brightness massive shadow at the left coronary ostium (dotted circle). Right, color flow on Doppler showed a mosaic image and accelerated blood flow (arrowhead)
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Fig3
There was a high-brightness massive shadow at the left coronary ostium (Fig. 3, left) where the color flow on Doppler showed a mosaic image (Fig. 3, right).
Anesthetic record.   start/end of surgery. PAP pulmonary artery pressure, CVP central venous pressure, AP arterial pressure, (1) start of CPB, (2) AVR, (3) withdrawal of CPB, (4) signs of left heart failure and appearance of left ventricular wall motion abnormality, (5) second run of CPB, (6) second withdrawal of CPB
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Fig4
Hemodynamics was stabilized following CPB (Fig. 4). 