Severe regurgitation due to perforation of the mitral-aortic intervalvular fibrosa 3 years after aortic valve replacement

We report the case of a 91-year-old man with severe symptomatic mitral regurgitation (MR), referred for assessment of percutaneous edge-to-edge repair 3 years after bioprosthetic aortic valve replacement (AVR). Detailed transthoracic, trans-oesophageal (TEE), and three-dimensional (3D) echocardiography showed a perforation in the subaortic curtain leading to severe regurgitation from the left ventricular outflow tract to the left atrium, which was undiagnosed on previous two-dimensional echocardiography. This regurgitation might be iatrogenic in origin after AVR in the absence of previous known endocarditis. This case highlights the utility and added value of 3D TEE in identifying the mechanism of MR.