Fig. 1

Midesophageal, long-axis, two-dimensional transesophageal echocardiography view of the mitral valve. A mild centrally directed mitral regurgitation (MR) due to compromised coaptation with a vena contracta of 2.3 mm was demonstrated before initiating cardiopulmonary bypass (CPB) (a). Following the first surgical aortic valve replacement (AVR), severe centrally directed MR with restriction and distortion of the anterior mitral leaflet was revealed (vena contracta, 8.6 mm), while there was no evident injury of the anterior mitral leaflet, ventricular enlargement, or myocardial hypokinesis (b). After re-AVR, there was no restriction or tethering of the anterior mitral leaflet and the MR was reduced to the same mild degree (vena contracta, 2.5 mm) as that before initiating CPB (c). LA, left atrium; LV, left ventricle; Ao, aorta