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The most common cause of cusp prolapse is due to a transverse fold of the right coronary cusp producing a partial and distal cusp prolapse (A, red arrow), with a very eccentric jet toward the anterior mitral leaflet (B, green arrows). The transverse fold can also be appreciated on the 2D short axis view (C, yellow arrow), as well as on 3D ‘en face’ view (D, blue arrow). The transverse fold can be identified at the time of surgery (E, black arrow).
