Unexpected transesophageal echocardiogram finding during an aortic valve replacement

Abstract

A 69-YEAR-OLD MAN was admitted with complaints of severe shortness of breath. On examination, the patient was found to have a harsh systolic murmur best auscultated at the left sternal border, and he had an irregularly irregular heart rhythm. Cardiac catheterization revealed the presence of severe aortic stenosis with an 80 mmHg gradient and an aortic valve area of 0.59 cm2. The coronary arteries showed no significant disease. The left ventricular ejection fraction was estimated at 49%. The mean right atrial pressure was 13 mmHg, the right ventricular pressure was 47/18 mmHg, and the mean pulmonary arterial pressure was 38 mmHg. The patient was scheduled for an elective aortic valve replacement. In the operating room, routine monitors were placed, including a pulmonary artery catheter and an arterial catheter. After induction, the mean pulmonary arterial pressure was 29 mmHg with a central venous pressure of 16 mmHg and a mean arterial pressure of 80 mmHg. The cardiac output was 10.8 L/min, with an endless curve noted on the display. A transesophageal echocardiogram probe was inserted, and Fig 1 was obtained. What is the diagnosis?