A 62-year-old man presented with acute decompensated heart failure. His medical history included heart failure with preserved ejection fraction and infective endocarditis. Two-dimensional transthoracic echocardiography (TTE) showed eccentric aortic insufficiency, the mechanism and severity of which could not be accurately determined because multiple jets were present (Fig. 1A and 1B). Three-dimensional (3D) transesophageal echocardiography (TEE) of the aortic valve showed major perforations in the right coronary and noncoronary cusps and small perforations in the left coronary cusp; moderate thickening was consistent with prior endocarditis (Fig. 1C and 1D). Visual examination of the excised aortic valve confirmed these findings (Fig. 2).