醫源性急性主動脈瓣閉鎖不全是主動脈瓣附近心臟手術的罕見併發症。主動脈瓣的易受傷性歸因於心臟纖維骨架的中心位置。在此我們報告一個接受二尖瓣置換術的個案，因為人工瓣膜的襯墊縫線導致無冠狀動脈瓣脫垂而產生醫源性嚴重主動脈瓣閉鎖不全。經由及時修補，經食道心臟超音波顯示僅有輕微主動脈瓣閉鎖不全。

Iatrogenic acute aortic regurgitation is a rare complication but can occur during cardiac surgery performed in the vicinity of aortic valve. The vulnerability of aortic valve is ascribed to its central location of the cardiac fibrous skeleton. Here we present a case of iatrogenic severe aortic regurgitation during mitral valve replacement because of non-coronary cusp prolapse caused by the traction of a pledgeted suture of mitral valve prosthesis. After prompt correction, transesophageal echocardiography revealed mild aortic regurgitation.