A 67-year-old male who had received an aortic porcine bioprosthesis 15 years previously, presented with unstable angina. The patient underwent percutaneous coronary intervention with the resolution of chest pain. A limited predischarge echocardiogram showed evidence of a newly severely elevated left ventricular filling pressure and new eccentric aortic regurgitation. Six days later, the patient reported symptoms of heart failure. Transesophageal echocardiography (TEE) revealed severe aortic regurgitation due to a torn/flail left coronary cusp; this was confirmed surgically and pathologically, and required aortic valve re-replacement. The present case highlights the value of indirect echocardiographic signs of aortic regurgitation and the value of TEE in the accurate identification of the mechanism of complex prosthetic valvular heart disease, with excellent pathological correlation. The temporal relationship between the valve tear and coronary intervention raises a point of caution and an awareness in the practice of catheter-based percutaneous procedures in patients with 'old' bioprosthetic aortic valves that are likely more prone to anatomic disruption.