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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).
Two-dimensional TTE and TEE are the conventional methods for the diagnosis and quantification of valvular heart disease. Because 3D echocardiography enables the acquisition of a 3D data set, it is emerging as a better noninvasive tool for the evaluation of valvular and other structural heart disease.1 The images that we acquired with use of 3D TEE definitively established the diagnosis of aortic valve perforation.
Address for reprints: Erick Avelar, MD, Director, Noninvasive Cardiac Imaging Program, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030