A 65-year-old female patient diagnosed with degenerative aortic valve disease and severe regurgitation on transthoracic echocardiography (TTE) also had severe mitral regurgitation (MR), but the exact mechanism of MR could not be determined. Transesophageal echocardiography (TEE) showed limited leaflet coaptation and a severe central MR jet. Further three-dimensional (3D) imaging revealed an indentation in the middle of P2 scallop almost reaching the annulus. This was consistent with the diagnosis of cleft posterior mitral valve leaflet. Unlike cleft anterior leaflet which can be clear on TTE short-axis images, cleft posterior leaflet may only be visible using 3D TEE. The identification of cleft posterior leaflet is essential in guiding surgical valve repair.
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