Aortic insufficiency from iatrogenic valve perforation from nonaortic valve operations is rarely reported despite the prevalence of these procedures. Rapid diagnosis of these defects is essential to prevent deterioration of cardiac function. In this paper, we describe a young man who reported to our institution after two open cardiac surgeries with new aortic regurgitation found to be due to an iatrogenic perforation of his noncoronary aortic valve cusp. This defect was not appreciated by previous intraoperative transesophageal echocardiography and was inadequately visualized on follow-up transthoracic and transesophageal echocardiograms. In contrast, cardiac gated computed tomography clearly visualized the defect and its surrounding structures. This case highlights the utility of cardiac gated computed tomography for cases of suspected valvular perforation when echocardiography is not readily available or inadequate imaging is obtained. 1. Introduction Aortic insufficiency resulting from iatrogenic aortic valve perforation during nonaortic valve cardiac operations is a rarely reported complication despite the prevalence of these procedures. Rapid diagnosis and treatment of these defects are essential in preventing deterioration of cardiac function. This case report describes a young man with a history of mechanical mitral valve placement in 2004 and reoperation at an outside facility in 2009 secondary to prosthetic valve endocarditis who presented to our institution two months after the second procedure with progressive dyspnea and decompensated heart failure. He was found to have new severe aortic regurgitation from an iatrogenic perforation of his noncoronary aortic valve cusp. Intraoperative transesophageal echocardiography (TEE) is established as an effective modality to detect these injuries during valvular replacement surgeries but in this case failed to detect a defect. Making the diagnosis involved use of transthoracic echocardiography (TTE), repeat TEE, and cardiac gated computed tomography (CT) to fully characterize the defect. This case highlights the diagnostic utility of cardiac CT in cases of new valvular insufficiency when iatrogenic injury is suspected. 2. Case Presentation In September 2004, a 24-year-old male presented with progressive dyspnea on exertion, paroxysmal atrial fibrillation, malaise, and peripheral eosinophilia. Initial evaluation showed a left atrial mass and a separate mass adherent to the mitral valve for which the patient underwent surgical resection and mechanical mitral valve replacement. The diagnosis of
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