A 66-year-old patient on the second day after biological mitral valve replacement surgery due to severe periprosthetic insufficiency. While extubated, he developed tachycardia, hypoperfusion and hyperlactacidemia, with the need for vasopressor medication and the deobstruction of drains due to large clots, followed by clinical improvement. This was followed by repeat worsening with the same clinical manifestations, requiring intubation and vasopressor medication. Transesophageal ultrasound showed an anterior hyperdense mass with a minimal right atrial imprint (Fig. 1) and left massive pleural effusion at apical-middle and basal level, with “hematocrit sign” (Fig. 2). The thoracic CT scan showed an anterior mediastinal hematoma with posterior communication with the left pleura, and contrast leakage at the internal mammary artery level (Fig. 3), requiring urgent surgery and polytransfusion (see Supplementary material). In recent years, transesophageal pulmonary ultrasound has experienced marked development in critical patients, affording an excellent complementary tool for assessing the posterior and deep regions of the lung with increased imaging quality.

Figure 1

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Figure 2

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Figure 3

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