Intraoperative transesophageal echocardiography (TEE) before sternotomy showed a moderate, unexpected eccentric jet of aortic regurgitation (Figure 2 and Supplementary Video 2). The preoperative left ventriculogram showed the multipurpose guiding catheter intermittently entering the aortic sinus (Figure 3 and Supplementary Video 3). Because aortic regurgitation was not present before catheterization, the catheter likely caused trauma to the aortic leaflet, resulting in aortic regurgitation. Two areas with defects were found during surgery: an apparent cleft in the right coronary cusp and a tear in the central right coronary cusp (Figure 4A). Aortic valve repair consisted of commissuroplasty between the right and noncoronary cusps, repair of the tear in the right coronary cusp, and resuspension of all 3 commissures (Figure 4B). Mitral valve repair, ligation of the left atrial appendage, and surgical CryoMaze of the left atrium were performed as planned. Follow-up TTE showed insignificant aortic regurgitation, trivial mitral regurgitation, and normal left ventricular ejection fraction.

Iatrogenic aortic regurgitation due to cardiac catheterization is a rare complication most often associated with aortic dissection.1) Few cases have been reported of iatrogenic aortic regurgitation due to aortic leaflet trauma during cardiac catheterization.2)3)4) This case highlights the importance of intraoperative TEE in identifying unexpected findings such as aortic regurgitation secondary to iatrogenic aortic valve cusp trauma.