An unexpected image on transesophageal echocardiography: A hyperechogenic ring on the aortic cusp

A 63-year-old male presented to the emergency department with a history of a sudden onset of shortness of breath and chest pain. The patient had prior coronary angiography in an external center due to acute coronary syndrome five years prior to admission. Due to severe left main coronary artery (LMCA) stenosis, a drug-eluting stent from the LMCA to the left anterior descending artery was implanted. Transthoracic echocardiography illustrated a dilated left ventricle (LV) with an estimated ejection fraction of 32% and moderate-to-severe mitral regurgitation and tachycardia. The patient was directly transferred for coronary angiography. During the procedure, the LMCA could not be cannulated with a Judkins left 4 (JL4) catheter and, therefore, a JL3.5 was used, and only selective images could be taken. Coronary angiography revealed multivessel disease, and coronary artery bypass grafting (CABG) was decided.