Clinical history and current illness
A 54-year-old man, of Uruguayan origin, who was living in our health care area for work reasons (as a transporter). He was admitted with heart failure and episodes of back pain.
 - No known drug allergies
 - Smoker of 1 pack of cigarettes/day
 - History of depressive syndrome
 - Hypertensive and dyslipidaemic
 - Carrier of chronic anti-aggregation atrial fibrillation. No previous cardiology assessment. - No family history of cardiovascular disease of interest
 - Home treatment: acetylsalicylic acid, digoxin, furosemide, pravastatin
 
Patient with the aforementioned history was admitted 4 days ago to the Digestive Service with a clinical diagnosis of cholelithiasis with suspicion of cholangitis, based on clinical manifestations of abdominal pain of increasing intensity, colicky, which intensified with palpation of the right hypochondrium and epigastrium, accompanied by fever and laboratory data compatible with infection (discrete leukocytosis -13450 leukocytes/uL- with left deviation -91% neutrophils with 8% casts).
During his stay in the Digestive Department, abdominal pain was controlled with the use of WHO scale 1 analgesics. However, in view of the marked clinical manifestations of right-sided heart failure, an echocardiogram was requested and a referral to the Cardiology Department was made. The transthoracic echocardiogram revealed a type A aortic dissection with a dilated root and severe aortic insufficiency, as well as severe mitral insufficiency with a dilated and dysfunctional left ventricle. In view of these findings, the patient was admitted to the Coronary Unit to complete the study (chest CT scan) prior to surgery.
On cross-examination, the patient reported progressive dyspnoea up to NYHA class II for a month and a half, and in the last week several episodes of back pain that required the administration of anti-inflammatory drugs. He did not clearly complain of chest pain.

Physical examination:
- Blood pressure: 120/80 mmHg. Heart rate: 88 bpm. Temperature: 36.7 °C.
- Good general appearance. Normal hydration, normal colour, normoperfused. Eupneic (SaO2 98% with nasal cannulae at 3 bpm).
- Head and neck: no goitre. Carotids rhythmic and without murmurs. No jugular venous engorgement at 45°.
- Cardiac auscultation: arrhythmic. Decreasing diastolic exhalation murmur in accessory aortic focus of intensity IV/VI Levine scale. Decreasing holosystolic murmur of IV/VI intensity in mitral focus with irradiation to the axilla.
- Pulmonary auscultation: preserved vesicular murmur with bibasal crackles.
- Abdomen: globular, soft, depressible. No masses palpable. Hepatomegaly of 2 finger widths. Discomfort on palpation in the right hypochondrium. No signs of acute abdomen. Peristaltic sounds preserved. No abdominal murmurs.
- Extremities: pulses present and symmetrical in the upper extremities. In lower limbs, presence of oedema with fovea up to the middle region of both legs, preventing the determination of peripheral pulses. Signs of venous insufficiency with no evidence of deep vein thrombosis.
- Neurological: no gross neurological focality.

Complementary tests
- ECG: atrial fibrillation at 88 bpm. Signs of left ventricular hypertrophy with evidence of systolic overload.
- CBC: haemoglobin 12.7 g/dL, haematocrit 40.7%, leukocytes 13830/uL (85% neutrophils, 8.3% lymphocytes), platelets 245000/uL; biochemistry: glucose 102 mg/ dL, urea 44.0 mg/dL, creatinine 1.1 mg/dL, total bilirubin 4.6 mg/dL, GOT/AST/ASAT 41 IU/L, GPT/ALT/ALAT 32 IU/L, GGT 70 IU/L, alkaline phosphatases 191 IU/L, CK 85 IU/L, troponin I 0.09 ng/dL, sodium 130 mMol/L, potassium 4.5 mMol/L; coagulation: quick's time 21.0, ratio 1.86, INR 1.84, aPTT 29.7, aPTT ratio 0.99.
- Chest X-ray: enlarged cardiopericardial silhouette with Kerley's B lines and right costophrenic sinus impingement.
- Echocardiogram: severely dilated left ventricle (DTD 78/DTS 67), with normal thickness (septum 10 and posterior wall 9 mm). Global hypokinesia more marked in anterior and septal territory, leading to severe left ventricular dysfunction (LVEF Teich 27%). Aortic valve trivava, with severe regurgitation flow (jet diameter adjusted by outflow tract diameter greater than 70%) secondary to anterior leaflet prolapse. Sclerosed mitral valve, with eccentric holosystolic insufficiency, towards the lateral wall of the left atrium, of severe degree (vena contracta 9 mm), secondary to dilatation of the mitral annulus (52 mm) with tenting of the posterior leaflet. Dilated left atrium (area 38 cm2). Dilated right ventricle (basal DTD 50 mm).
Moderate tricuspid insufficiency, with RV-AD gradient 25 mmHg. TAPSE 16 mm. Dilated vena cava (26 mm) with <50% collapse. Aneurysmal ascending aorta (59 m) with an image suggestive of flap about 20 mm from the aortic root showing double lumen. It is not possible to assess the aortic arch. Slight pericardial effusion at the level of the roof of the right atrium.
- Thoracic CT: aneurysm in the ascending thoracic aorta with diameters: in the valvular annulus: 3.7x3.5 cm, in the sinus portion 5.4x5.9 cm, in the sinotubular junction 5.2x5.1 cm, maximum in the ascending aorta: 6.86x6.4 cm, anterior to the brachiocephalic trunk exit: 4.5x4.4 cm, posterior to the brachiocephalic trunk exit: 4x3.4 cm, in the descending aorta: 3.2x3 cm. Type A aortic dissection starting in the sinus plane of the ascending thoracic aorta and extending to the descending thoracic aorta (2 cm distal to the origin of the left subclavian artery). There is a focal haematoma/thrombus at the origin of the dissection which occupies the non-coronary sinus and extends into the region of the sinotubular junction. All three supra-aortic trunks and both carotids originate from the true lumen. Multiple repletion defects in the pulmonary arterial tree in association with pulmonary thromboembolism. At the level of the right pulmonary tree: in the right superior lobar artery with extension to its three segmental branches and several sub-segmental branches and in the bifurcation of the middle lobar artery with extension to its two segmental branches. At the level of the left pulmonary tree: in multiple segmental and subsegmental arteries of the LSI (including lingular arteries) and LII. Multiple peripheral focal pulmonary opacities in the right upper hemithorax and consolidations in the posterior regions of both lower lobes (more prominent in the left) compatible with areas of atelectasis and/or infarction. Bilateral pleural effusion.
Hepatomegaly with diffuse altered enhancement in relation to stasis liver. This finding together with an increased calibre of the inferior vena cava (slightly larger than the adjacent abdominal aorta), the diffuse infiltration of the abdominal subcutaneous fat and the minimal amount of perirenal fluid suggest altered haemodynamic status due to probable right heart failure. Gall bladder stone measuring 2.3x1.7x3 cm in relation to cholelithiasis.

Clinical course
A 54-year-old man was admitted to the Coronary Care Unit from the Digestive Department where he had been admitted for cholelithiasis under study. The reason for his transfer was a type A aortic dissection, in the context of biventricular dysfunction with severe aortic and mitral insufficiency, both of them severe. As a serious associated comorbidity, he also presented bilateral pulmonary thromboembolism with acceptable haemodynamic tolerance.
Given the coexistence of both entities and the initial clinical and haemodynamic stability of the patient, it was decided to manage the patient conservatively at first, trying to resolve the heart failure data and see the evolution of the pulmonary arterial pathology, as there was a limitation in the use of anticoagulation at recommended doses in the presence of aortic dissection. In addition, a venous echo-Doppler of the lower limbs was performed, which ruled out the presence of deep vein thrombosis that could justify the implantation of a cava filter to prevent recurrence of pulmonary thromboembolism in a patient limited to anticoagulation.
However, in subsequent days the patient evolved unfavourably, with recurrent episodes of chest pain and cardiac arrest secondary to electromechanical dissociation that required advanced cardiopulmonary resuscitation manoeuvres, which were successfully resolved. The emergent echocardiogram ruled out cardiac tamponade and the emergent aortic angio-CT ruled out aortic rupture or associated complications, although it showed retrograde progression of the aortic dissection towards the right sinus of Valsalva without involvement of the right coronary artery. In view of this clinical situation, the decision was made to perform urgent surgery. A Bentall procedure was performed with a valved tube and mitral annuloplasty with a Carpentier ring, and the patient died in the operating theatre after unresponsive cardiac arrest.

Diagnosis
- Type A aortic dissection
- Bilateral pulmonary thromboembolism
- Severe biventricular dysfunction
- Severe aortic and mitral regurgitation
