A case report on deceptive strands or diagnostic clues: aortic valve chordae through the eyes of multi-imaging cardiology guiding 'the scalpel'.

Background: Aortic valve chordae tendineae (AVCT) are rare anomalies that can mimic common causes of aortic insufficiency, such as vegetations or fibroelastomas. Advances in multimodality imaging have improved the diagnosis and management of AVCT. Case presentations: We present two cases of patients with severe aortic insufficiency where multimodality imaging was pivotal in diagnosing AVCT. Transthoracic echocardiography (TTE) initially identified the regurgitation, but further evaluation with transoesophageal echocardiography (TEE), cardiac computed tomography angiography (CCTA), and cardiac magnetic resonance imaging (CMR) confirmed the presence of fibrous strands extending from the aortic valve to the ascending aorta and left ventricular outflow tract. Both cases highlight the utility of advanced imaging in differentiating AVCT from other valvular pathologies. Discussion: TTE remains the initial tool for diagnosing valvular heart disease, but its limitations necessitate additional imaging modalities like TEE, CCTA, and CMR. CCTA was crucial for anatomical definition and exclusion of other pathologies. At the same time, CMR provided insights into myocardial remodelling and tissue characterization, including novel findings of the absence of late gadolinium enhancement (LGE) in AVCT lesions. These imaging modalities collectively provided a comprehensive diagnostic picture, informed treatment decisions, and guided surgical planning. Conclusion: This report highlights the importance of multimodal imaging in diagnosing AVCT, which aids in therapeutic decisions and reduces misdiagnosis risk. The combination of TTE, TEE, CCTA, and CMR offers a comprehensive evaluation, enhancing understanding of this rare condition. The absence of LGE in AVCT may help differentiate it from other valvular disorders.