Ruple J Galani, MD, FACC; James Thomas, ARDMS; Thomas Beaver, MD, MPH
A 62 year old white male presented to the outpatient echocardiography laboratory for evaluation of shortness of breath. Five years prior, he had mechanical aortic valve replacement for a bicuspid aortic valve. His history is also significant for hypertension, tobacco abuse, and moderate alcohol use. He has had no evaluation for his mechanical aortic valve since surgery.
Resting blood pressure was noted to be 170/100 mmHg. Immediately upon parasternal long imaging, it was noted the patient had a large ascending aortic aneurysm of nearly 8 cm. There was no evidence of proximal aortic dissection, aortic regurgitation, or pericardial effusion. Left ventricular function was normal.
The patient was immediately taken to the emergency room and started on an Esmolol drip for blood pressure control. A CT scan of the chest and abdomen confirmed a large 8.7 cm ascending aortic aneurysm with a Type A aortic dissection (Image 1). The patient was transferred to an academic tertiary care center. There it was felt the dissection was chronic and surgery was not emergent. He underwent left heart catheterization that showed no critical coronary disease. After complete dental extraction, he underwent successful aortic root and arch replacement. Prior to replacement, the aortic aneurysm and dissection had increased to nearly 12 cm (Image 2).
For patients who undergo isolated aortic valve replacement for a bicuspid aortic valve, close post-operative monitoring of the ascending and thoracic aorta for aneurysm must take place. In up to 10% of patients post aortic valve replacement, ascending aortic aneurysms that require repeat surgery can develop.
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