A 61-year-old man with a history of coronary artery bypass grafting and aortic valve replacement presents with worsening fatigue and dyspnea on exertion for the past 3 months. About 1 month ago, he noted a twinge of chest pain and, following this, his symptoms became much worse. He denies fever, chills, or rigors. On presentation to the emergency room, he is found to be in florid hypoxic respiratory failure and is intubated.

On physical exam, blood pressure is 161/45 mm Hg, pulse is 110 beats per minute and regular, neck veins are distended, and carotid pulses are brisk. Lungs are clear to auscultation bilaterally. Cardiac exam reveals a well-healed midline scar, a normal S1 and S2 with no S3 or S4 gallops. There is a 3/6 continuous murmur in the left upper sternal border that is nonradiating. Extremities are cool with no peripheral edema.

The patient undergoes a transesophageal echocardiogram (TEE) shown in Videos 44-1 to 44-4.