Aortic Transvalvular Gradient Mis-Quantification

Mitral regurgitation (MR) can occasionally mimic aortic stenosis (AS) on echocardiographic Doppler imaging, leading to diagnostic challenges. We present the case of a 55-year-old man undergoing minimally invasive mitral valve surgery for severe MR caused by posterior mitral valve leaflet prolapse. Preoperative transthoracic echocardiography revealed severe MR with no significant aortic valve abnormalities. Intraoperative transesophageal echocardiography (TEE) initially showed a high transvalvular aortic gradient (3 m/s) in the transgastric long-axis view, suggestive of mild-to-moderate AS. However, detailed Doppler analysis revealed a double envelope signal, representing both eccentric MR and true aortic valve flow. The closer evaluation showed the MR signal occurred earlier in the cardiac cycle, aligning with its hemodynamic timing, while the true aortic flow followed isovolumetric contraction. Subsequent three-dimensional TEE confirmed normal aortic valve morphology and function. This case highlights the importance of correlating preoperative findings, Doppler signal timing, and imaging data to avoid misdiagnosis. Systematic echocardiographic evaluation, including signal timing analysis, can differentiate between MR and AS, ensuring accurate intraoperative decision-making and preventing unnecessary interventions.