AN 83-YEAR-OLD, 71-kg, 168-cm man was admitted to the authors' medical center for the evaluation of progressive chest tightness, dyspnea on exertion, and dizziness of 6 months' duration. His past medical history was notable for essential hypertension; type 2 diabetes mellitus; and hyperlipidemia for which he was treated with hydrochlorothiazide, oral hypoglycemic drugs, and simvastatin, respectively. A harsh, grade III to IV of VI systolic murmur was heard throughout the precordium, but the remainder of the physical examination was noncontributory. Transesophageal echocardiography was performed as part of the evaluation and revealed the presence of a very heavily calcified, trileaflet aortic valve (Fig 1). Continuous-wave Doppler interrogation indicated that the peak and mean gradients across the valve were 68 and 44 mmHg, respectively (Fig 2), which is consistent with the diagnosis of severe aortic stenosis. The aortic valve area was estimated as 0.72 cm2 using the continuity equation. A midesophageal aortic valve long-axis color Doppler image indicated 2 distinct routes of aortic blood flow through the stenotic valve during systole (Fig 3 and Video 1 [supplementary videos are available online]) and diastole (Fig 4). What is the cause of this dual pattern of aortic blood flow? Is a leaflet perforation responsible for these findings? Fig 2Continuous-wave Doppler echocardiographic velocity-time waveforms obtained from the deep transgastric imaging plane showing peak and mean gradients across the aortic valve of 68 and 44 mmHg, respectively. View Large Image Figure Viewer Download Hi-res image Fig 3A midesophageal aortic valve long-axis color Doppler image obtained during mid–left ventricular systole showing blood flow through a central zone between the aortic valve leaflets and a second region adjacent to the posterior annulus. View Large Image Figure Viewer Download Hi-res image Fig 4A midesophageal aortic valve long-axis color Doppler image obtained during left ventricular diastole showing 2 small jets of aortic regurgitation from a central zone and adjacent to the posterior annulus (trace). View Large Image Figure Viewer Download Hi-res image