Clinical introduction

A previously well patient aged 20-plus years, underwent laparotomy following abdominal stab injuries. Bowel lacerations were identified and closed. Through a diaphragmatic defect, a small right atrial puncture was noted which was closed with cardiothoracic surgical assistance. No further injuries were identified. The patient was intubated and ventilated and on inotropic support with a blood pressure of 140/40 mm  Hg. The patient's blood pressure later dropped to 100/30 mm Hg and plans were made for further abdominal imaging and re-laparatomy. In the meantime, transthoracic echocardiography (TTE) showed good left and right ventricular function and there was no pericardial effusion. However, the echocardiogram suggested severe aortic regurgitation (figure 1A), and there was a suspicious colour Doppler flow signal noted (figure 1B) through which continuous-wave Doppler velocities were recorded (figure 1C).