A 64-year-old man was admitted to our department because of recent onset of weakness and shortness of breath. He had undergone a surgical mitral commissurotomy in 1977 and a bioprosthetic mitral replacement in 2004. The clinical presentation demonstrated normal blood pressure, no signs of congestive heart failure, no fever and a 3/6 systolic mitral murmur; he was in permanent atrial fibrillation.
Transthoracic echocardiography showed severe left atrial enlargement and the presence of a paravalvular leak. Two-dimensional (2D) transoesophageal echocardiography (TEE) clearly demonstrated severe paravalvular regurgitation ( Fig. 1 A ) but real-time three-dimensional (3D) TEE allowed precise location of the paravalvular regurgitant jet at the inferomedial part of the annulus, slightly distant from the prosthetic ring, with a circular and expansive shape ( Fig. 1 B). On colour-flow Doppler imaging, the area of dehiscence was estimated as being close to 0.7 cm 2 ( Fig. 1 C and D). Owing to the high risk of a third surgical procedure, the absence of signs of congestive heart failure or haemolysis and the requirement of only a minor dose of diuretics, the patient was discharged with a scheduled visit at 1 month.
