• Images in cardiology

A 70 year old man presented with infective endocarditis caused by Streptococcus pyogenes complicated by severe mitral and pulmonary oedema. Transthoracic echocardiography showed severe mitral regurgitation and echodensities on the mitral anterior leaflet consistent with vegetation.

Transoesophageal echocardiography disclosed a free floating circular image within the left atrium with “Saint’s halo” or “ UFO-like” appearance in 0–70° orthogonal planes, and a systolic jet through that image (below left). Multiplane assessment revealed that the circular image was a cross section of a ruptured and aneurysmally dilated mitral anterior leaflet resulting in severe mitral regurgitation (below centre and right). Vegetation on the mitral anterior leaflet, caused by perforation of the leaflet, was also detected. The patient underwent open heart surgery, and following an unsuccessful attempt to repair the perforated mitral anterior leaflet, the mitral valve was replaced by a mechanical one. Periodic follow up and echo evaluations have revealed no problem to date.