"Holes-in-one": A case of concurrent windsock mitral valve, root abscess, and Gerbode defect

Infective endocarditis is a heterogeneous disease with a wide array of pathological lesions. We present a 55-year-old man with severe mitral and aortic regurgitation on transthoracic echocardiography. Transesophageal echocardiogram characterized the mechanisms detecting a windsock mitral valve perforation, aortic root abscess, and Gerbode ventricular septal defect, with the deep transgastric view showing all three pathologies concurrently. The etiologies of mitral valve perforation and Gerbode defects are discussed. Transesophageal echocardiography remains a critical imaging modality to diagnose and evaluate the extent of infective endocarditis with superior sensitivity to transthoracic echocardiography.