case_images: PMC7307623_01
case_images: Postimplantation angiographic image showing a low deployment of the CoreValve prosthesis in the left ventricular outflow tract (white arrows) and the incomplete stent expansion (yellow arrows)
case_images: JCE-30-44-g001.jpg
case_images: PMC7307623_01_JCE-30-44-g001.jpg
case_images: F1
case_images: The procedure was uneventful although an optimal depth was not reached, resulting in a low deployment of the prosthesis in the left ventricular outflow tract and reduced stent expansion [Figure 1]. Patient medical history also included stable coronary artery disease treated with percutaneous revascularization of the left anterior descending and right coronary arteries. Transthoracic echocardiography showed degenerative mitral valve disease with a central moderate-to-severe regurgitant jet.
case_images: Transthoracic echocardiography (parasternal long-axis zoom mode). Color Doppler examination revealing the presence of a regurgitant jet originating from the basal portion of the anterior mitral leaflet near the mitral-aortic curtain (yellow arrow)
case_images: JCE-30-44-g002.jpg
case_images: PMC7307623_01_JCE-30-44-g002.jpg
case_images: F2
case_images: However, color Doppler analysis showed a second anomalous regurgitant jet raising the suspicion of mitral leaflet perforation [Figure 2].
case_images: (a and d) Transesophageal examination revealing the perforation of the anterior mitral leaflet where it made contact with the proximal edge of the CoreValve stent. Two filamentous structures are present on both edges of the perforation (yellow arrows). (b and c) Color Doppler interrogation showing the presence of a large intraleaflet regurgitant jet from left ventricular outflow tract to left atrium (yellow arrows). Another second interleaflet regurgitant jet is present (white arrows)
case_images: JCE-30-44-g003.jpg
case_images: PMC7307623_01_JCE-30-44-g003.jpg
case_images: F3
case_images: This perforation resulted in a large regurgitant jet directed from the left ventricular outflow tract to the left atrium [Figure 3a-d].
case_images: (a and b) Three-dimensional transesophageal echocardiography (zoom mode) better defines the site and size of mitral leaflet perforation and the presence of two vegetations (yellow arrows)
case_images: JCE-30-44-g004.jpg
case_images: PMC7307623_01_JCE-30-44-g004.jpg
case_images: F4
case_images: Last but not least, two filamentous structures (about 9 mm each) on both edges of the perforation site were noticed raising the suspicion of IE [Figure 4a and b].
case_images: (a and b) Computed tomography angiography revealing the presence of an ascending aorta ulcer on the distal edge of the prosthetic valve stent (yellow arrows). (c) The stent frame is grossly underexpanded (red asterisk)
case_images: JCE-30-44-g005.jpg
case_images: PMC7307623_01_JCE-30-44-g005.jpg
case_images: F5
case_images: The computed tomography (CT) angiography was unable to better define the mitral leaflet perforation; however, it revealed the presence of an ascending aorta ulcer on the distal edge of the prosthetic valve stent [Figure 5a and b]. Furthermore, CT showed the underexpansion of the aortic prosthetic valve stent [Figure 5c].