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A 67-year-old male patient presented to emergency department with worsening altered mental status and fever. Computerized tomography (CT) of head found patient with multiple basal ganglia infarcts with high suspicion for septic emboli as sources for stroke. Blood cultures and lumbar puncture obtained and the patient was found to have Streptococcus pneumonia meningitis. A two-dimensional (2D) transthoracic echocardiogram (TTE) demonstrated severe aortic regurgitation and flail leaflet with an ejection fraction of 70%. Cardiology and cardiothoracic surgery were consulted for the valvulopathy in conjunction with elevated troponins, bacteremia, and bacterial meningitis. A transesophageal echocardiogram (TEE) showed a perforation of the right coronary cusp resulting in severe aortic regurgitation (Figures 1A and 1B), a reversal of flow into the thoracic aorta due to the severe aortic regurgitation and reduction in ejection fraction from the time the TTE was performed. His hospital course was further complicated with newonset of atrial fibrillation. Three-dimensional (3D) TEE provided an exceptional understanding of the changing size and shape of the perforation of the cusp with the cardiac cycle (Figures 1C and 1D). While there are methods to assess the regurgitant orifice area by the 2D echo to determine the severity of aortic regurgitation, the 3D data clearly shows that the regurgitant orifice is a highly dynamic structure with the change in shape and size influenced by systole and diastole. A perforated cusp is a major structural abnormality and carries with it severe regurgitation. While 3D imaging in our case may not have altered the management of the patient, it did enhance the understanding of the pathology from an imaging perspective and challenges the 2D echo-derived assumption of a fixed regurgitant orifice. The patient was placed on intravenous (IV) antibiotic therapy with good response with repeat negative blood cultures. Patient was deemed high-risk for a surgical procedure but his risk of mortality remained high without aortic valve procedure. He subsequently underwent aortic valve replacement using a 23 mm mechanical valve, left atrial appendage closure and debridement of abscess found under the right coronary cusp. He had a difficult recovery post-operatively with weaning off the ventilator, but eventually improved.

Dynamic Shape Change of an Aortic Valve Cusp Perforation on 3D Transesophageal Echocardiogram