A 48-year-old man was referred to our institution for follow-up echocardiography. Five years previously, he underwent a coronary artery bypass graft and a mitral valve annuloplasty for severe symptomatic functional MR due to an inferior myocardial infarction. Postoperative echocardiography showed mild MR and, more surprisingly, new mild AR of unclear mechanism. In May 2010, he was admitted for IE with mitral valve vegetations but no MR increase and the same posterior mild AR (and no sign of aortic IE). Both TTE and TEE were performed at that time. The patient fully recovered after 6 weeks of antibiotic therapy and the last TEE showed complete disappearance of mitral vegetations with the same mild AR. The patient was readmitted in October 2010 for follow-up echocardiography at 6 months. Physical examination was unremarkable, he was apyretic and there was no murmur. There were no clinical or biological arguments for endocarditis. TTE showed mild MR and, again, mild AR, which seemed to originate from the non-coronary leaflet ( Fig. 1 ). The origin of the AR jet was surrounded by bright spots. TEE was done and the same findings were observed. At the same time, three-dimensional acquisitions were performed and clearly showed perforation of the non-coronary leaflet ( Fig. 2 ).
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