Clinical introduction A man in his 50s presented with abscessed aortic valve methicillin-sensitive Staphylococcus aureus endocarditis, received intravenous antibiotics and underwent bioprosthetic aortic valve replacement with removal of all infected tissues. He returned 18 days later with severe dyspnoea, subjective fever and bilateral lower extremity oedema. Physical examination revealed tachypnoea and tachycardia without fever, prominent neck CV waves visible at 90°, left parasternal heave, 3/6 holosystolic murmur across the precordium, lung rales and severe peripheral oedema. C reactive protein was 211 mg/L (normal <8 mg/L). Blood cultures were obtained. ECG showed sinus tachycardia and right axis deviation. Transthoracic echocardiogram (TTE) parasternal zoomed short-axis systolic frame (figure 1A, B), apical four-chamber systolic frame (figure 1C) and subcostal continuous wave (CW) Doppler (figure 1D), are shown.

Question Given the clinical presentation and TTE findings, what is the diagnosis?

1. Severe tricuspid regurgitation due to extension of endocarditis

2. Aortic valve obstruction resulting in severe pulmonary hypertension

3. Acquired Gerbode defect

4. Aortic valve dehiscence with severe paraprosthetic regurgitation