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Events

Day 0

A 26-year-old woman with a background of bicuspid aortic valve (BAV) and aortic regurgitation (AR) presents to the emergency department with congestive heart failure and diastolic and systolic murmurs.

Transthoracic echocardiogram (TTE) shows severe AR, a ‘thickened’ TV with new, moderate–severe tricuspid regurgitation (TR) and right ventricular (RV) dilatation. Abnormal forward flow through the TV is noted.

Day 4

Transoesophageal echocardiogram appearances show an aorto-right atrial (RA) connection with abnormal continuous TV forward flow on Doppler concerning for a RSOVA with concurrent moderate–severe TR. Further imaging is perused to assess tricuspid annular involvement due to disproportionately severe TR.

Day 6

Computer tomography angiogram shows pan-cardiac contrast enhancement despite appropriate electrocardiographic gating resulting in impaired tricuspid annular assessment. A RSOVA ‘windsock’ prolapse through the TV is noted.

Day 8

Agitated saline ‘bubble’ contrast study demonstrates a RA filling defect coursing through the TV without a defect within the RV.

Day 12

Cardiac magnetic resonance (CMR) imaging confirms a RSOVA immediately basal to the tricuspid annulus with continuous, high-velocity flow along the anterior tricuspid leaflet into the RV suggesting a spared annulus.
Review of TTE images demonstrates TV malcoaptation due to ‘windsock’ prolapse and forced systolic TV leaflet opening due to high-velocity RSOVA flow resulting in disproportionately severe TR.

Day 33

The patient is adequately diuresed and undergoes surgical repair of the RSOVA with TV repair and annuloplasty. Position of the RSOVA is confirmed immediately basal to the TV annulus.

2 months

Patient is recovering well and is near baseline on follow-up.

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Time	Events
Day 0	A 26-year-old woman with a background of bicuspid aortic valve (BAV) and aortic regurgitation (AR) presents to the emergency department with congestive heart failure and diastolic and systolic murmurs.
Day 0	Transthoracic echocardiogram (TTE) shows severe AR, a ‘thickened’ TV with new, moderate–severe tricuspid regurgitation (TR) and right ventricular (RV) dilatation. Abnormal forward flow through the TV is noted.
Day 4	Transoesophageal echocardiogram appearances show an aorto-right atrial (RA) connection with abnormal continuous TV forward flow on Doppler concerning for a RSOVA with concurrent moderate–severe TR. Further imaging is perused to assess tricuspid annular involvement due to disproportionately severe TR.
Day 6	Computer tomography angiogram shows pan-cardiac contrast enhancement despite appropriate electrocardiographic gating resulting in impaired tricuspid annular assessment. A RSOVA ‘windsock’ prolapse through the TV is noted.
Day 8	Agitated saline ‘bubble’ contrast study demonstrates a RA filling defect coursing through the TV without a defect within the RV.
Day 12	Cardiac magnetic resonance (CMR) imaging confirms a RSOVA immediately basal to the tricuspid annulus with continuous, high-velocity flow along the anterior tricuspid leaflet into the RV suggesting a spared annulus. Review of TTE images demonstrates TV malcoaptation due to ‘windsock’ prolapse and forced systolic TV leaflet opening due to high-velocity RSOVA flow resulting in disproportionately severe TR.
Day 33	The patient is adequately diuresed and undergoes surgical repair of the RSOVA with TV repair and annuloplasty. Position of the RSOVA is confirmed immediately basal to the TV annulus.
2 months	Patient is recovering well and is near baseline on follow-up.

Time	Events
Day 0	A 26-year-old woman with a background of bicuspid aortic valve (BAV) and aortic regurgitation (AR) presents to the emergency department with congestive heart failure and diastolic and systolic murmurs.
Day 0	Transthoracic echocardiogram (TTE) shows severe AR, a ‘thickened’ TV with new, moderate–severe tricuspid regurgitation (TR) and right ventricular (RV) dilatation. Abnormal forward flow through the TV is noted.
Day 4	Transoesophageal echocardiogram appearances show an aorto-right atrial (RA) connection with abnormal continuous TV forward flow on Doppler concerning for a RSOVA with concurrent moderate–severe TR. Further imaging is perused to assess tricuspid annular involvement due to disproportionately severe TR.
Day 6	Computer tomography angiogram shows pan-cardiac contrast enhancement despite appropriate electrocardiographic gating resulting in impaired tricuspid annular assessment. A RSOVA ‘windsock’ prolapse through the TV is noted.
Day 8	Agitated saline ‘bubble’ contrast study demonstrates a RA filling defect coursing through the TV without a defect within the RV.
Day 12	Cardiac magnetic resonance (CMR) imaging confirms a RSOVA immediately basal to the tricuspid annulus with continuous, high-velocity flow along the anterior tricuspid leaflet into the RV suggesting a spared annulus. Review of TTE images demonstrates TV malcoaptation due to ‘windsock’ prolapse and forced systolic TV leaflet opening due to high-velocity RSOVA flow resulting in disproportionately severe TR.
Day 33	The patient is adequately diuresed and undergoes surgical repair of the RSOVA with TV repair and annuloplasty. Position of the RSOVA is confirmed immediately basal to the TV annulus.
2 months	Patient is recovering well and is near baseline on follow-up.

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