Medical history and current illness
A 61-year-old man consulted for dyspnoea and chest pain. AP: long-standing IDDM. Diabetic retinopathy (photocoagulation). DLP. Smoker of 1 pack/day until September 2011 (No COPD). Recurrent spixtasis in 2008, requiring arteriography and embolisation of both internal maxillary arteries. Admission in September 2009: self-limited confusional disorder with normal tests (CT, MRI and EEG), classified as probably of ischaemic origin. AE: admission in September 2011: exertional angina + HF NYHA functional class II of two weeks' evolution. EF: systolic murmur in aortic focus with reduction of aortic component of 2R that does not disappear. 4R present. No crackles.

Complementary tests
- CBC: glucose, renal function and ions normal. Serial CK and TnT US normal. Normal liver profile. ProBNP 1256. Normal haemogram.
- ECG: Sinus rhythm at 65 bpm, constant PR, narrow QRS, scarce growth of R in precordials. Left axis.
- Chest X-ray: cardiac silhouette of normal size. Pulmonary parenchyma without findings of interest.
- Echocardiography: LA: normal size. Moderate-severe concentric LVH, without segmental contractility defects, preserved LVEF. RV: normal. MV and TVR: normal. Bicuspid aortic valve severely calcified and very unstructured with significant restriction to valve opening, without being able to adequately record transvalvular gradients. Ascending aorta dilated from the root (45mm).
- Coronary angiography: LMCA without lesions. LAD with severe lesion at the beginning of bifurcational middle segment with diagonal branch, good distal beds. ACX without significant lesions. ACD with moderate lesion in the middle segment, rest of the vessel without lesions. Severe AoS with peak-to-peak gradient 50 mmHg.
- Angio-CT aorta: diffuse aneurysmal dilatation of the aortic root and ascending aorta (measuring 45x46 mm). Normalises diameter from the aortic arch (maximum arch diameter 28 mm, proximal descending thoracic aorta 28 mm, distal descending thoracic aorta 22 mm.

Clinical evolution
He progressed favourably on the Cardiology ward with diuretic treatment which was subsequently suspended, in addition to: ASA 100 mg 1cp/24h, bisoprolol 5 mg 1cp/12h, simvastatin 40 mg 1cp at dinner, ramipril 10 mg 1cp at breakfast, omeprazole 20 mg 1cp at breakfast, NTG patch 10 mg 9-23h, insulin Humalog mix 21-22-21. He was considered to require aortic valve replacement surgery, repair of the ascending aorta (valved tube) and coronary artery bypass surgery. He was discharged home on 6 October 2011. Preferential appointment was requested for cardiac surgery. She was readmitted on 16 October 2011 due to chest pain with an ischaemic profile and decompensated heart failure in acute pulmonary oedema. He required NIMV and was admitted to the coronary ICU, being discharged to the cardiology ward after a good clinical evolution three days later. He presented an episode of AF with RVR reverting to RS after PC of amiodarone. ECG unchanged. Serial myocardial damage enzymes were normal. Echocardiography was repeated: severe AoS, peak gradient 69 mmHg, mean gradient 43 mmHg, peak velocity 4.2 m/s, gradients recorded in the right parasternal plane. Given the negative clinical evolution of the patient on the ward, a transfer to the Cardiac Surgery Department of his reference hospital was requested on 27 October. He was admitted to the Cardiac Surgery Department from 27 October to 1 December 2011. Repeat PPCC: new CNG: severe bifurcated lesion of the medial LAD and diagonal branch. Preoperative echocardiography: calcified aortic valve with very reduced opening, maximum gradient 70 mmHg, mean 40 mmHg (could be underestimated). Aortic root measurements 45 mm (in sinuses of Valsalva); 43 mm (tubular level). Aortic annulus 28 mm. LV with septal hypertrophy 18 m, not dilated with EF 64%. Imaging test recommended to better define the dimensions of the ascending aorta (not performed). Intervention on 9 November 2011: resection of aortic valve: Mitroflow biological prosthesis no. 25. Elongated aorta, no impression of great disproportion with the rest of the cardiac structures. DA of good quality. Mammary bypass is performed to ADA. Good anoxia and pump output. Left pleural drainage and two mediastinal drains.  Postoperative: moderate pericardial effusion associated with haemodynamic instability (required amines). Exploratory re-intervention: abundant clots stuck to the LV, cavity cleaning was performed (NO active bleeding point). Evolution: purulent secretions through orotracheal tube and leukocytosis→ treatment: piperacillin/ tazobactam. Left pleural effusion (serohematic). Episodes of AF requiring amiodarone CP. Discharge to the ward in RS. Postoperative echocardiography: moderate LVH, without dilatation, postoperative septal alterations with slight loss of septal thickening and hypokinesia, hypokinesia and loss of inferobasal thickening. LVEF 50-57%, aortic prosthesis with peak gradient 13 mmHg, mean 5 mmHg. Normal areas (2.6 cm2) without regurgitation, normal mitral valve, reversed diastolic pattern, no PHT, dilated IVC(17 mm), partially collapsible→↑PVC, Minimal posterior pericardial effusion (7 mm), slight bibasal pleural effusion. Treatment at discharge: fat-free heart-healthy diet, omeprazole 20 mg 1cp/24h, ASA 100 mg 1cp/24h, bisoprolol 2.5 mg 1cp/12h, simvastatin 40 mg 1cp at dinner, furosemide 40 mg 1cp at breakfast, ramipril 5 mg 1cp/12h, amiodarone 200 mg 1cp/24h, deflazacort 30 mg in descending pattern. Insulin therapy adjustments by Endocrinology.

Diagnosis
- Severe aortic stenosis with bicuspid valve
- Dilatation of aortic root and ascending aorta (45-46 mm)
- Severe bifurcated lesion of the anterior descending artery in its middle segment and diagonal branch Aortic valve replacement with Mitflow biological prosthesis no. 25.
