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Endocarditis of bicuspid aortic valve (BAV) can lead to valve perforation and result in severe aortic incompetence. Perforation of valve cusps should be considered in the differential diagnosis of BAV patients presenting with AR, and the condition should not be mistaken as a regurgitant trileaflet AV on transesophageal echocardiography (TEE). Accurate preoperative characterization of the mechanism of aortic regurgitation by TEE is important for determining the type of surgical repair.

Perforation of Bicuspid Aortic Valve mimicking Trileaflet Aortic Valve on Transesophageal Echocardiography