Clinical history and current illness
A 66-year-old man came to the emergency department for progressive dyspnoea after a respiratory infection. No known cardiovascular risk factors. No toxic habits. Under study for probable OSA. Cataract surgery years ago without complications. The patient came to the emergency department of our centre for progressive exertional dyspnoea of one week's evolution, following a lower respiratory tract infection with cough and greenish expectoration. There was no documented fever, although there was a feeling of dystrophy during the first few days of the episode. No other symptoms.
Physical examination: 37.6 oC, BP: 140/50 mmHg, HR: 100 bpm. Pulse was clear, no signs of jugular venous engorgement. AP: crackles in both bases, hypophonesis in right base. AC: rhythmic tones, aortic regurgitant diastolic murmur grade 3/6. Abdomen without alterations. No oedema in the lower limbs.

Complementary tests
The following complementary tests were performed:
- ECG: sinus rhythm at 95 bpm. Normal PR segment. Signs of left ventricular enlargement. Left anterior hemiblock. No repolarisation alterations.
- CBC: normal haemogram, basic biochemistry and normal ions.
- Chest X-ray: signs of vascular redistribution, interstitial oedema in lower fields and bilateral pleural effusion, predominantly on the right. No apparent parenchymal infiltrates.
- Transthoracic echocardiogram: dilated left ventricle with end-diastolic diameter of 65 mm and end-systolic diameter of 40 mm, with hyperdynamic global systolic function. An aortic insufficiency jet was detected, which was difficult to quantify as it was an eccentric jet that collided with the anterior mitral leaflet, and was suggestive of significant aortic insufficiency. Absence of mitral valve disease. Normal right chambers with pulmonary systolic pressure not estimable in the absence of tricuspid insufficiency, with no indirect evidence of pulmonary hypertension. No vegetations or other signs of endocarditis visible by this technique, no other pathological findings.
- Blood cultures (x2) in two batches taken, one before and one after the start of antibiotic treatment: negative Clinical evolution Treatment was started with diuretics and angiotensin-converting enzyme inhibitors, in addition to antibiotic treatment with amoxicillin-clavulanic acid, with excellent clinical evolution. Following clinical improvement, a transesophageal echocardiogram was performed to evaluate the cause of the aortic regurgitation. This test documented severe aortic regurgitation due to severe prolapse (flail) of one of the valve leaflets, causing an eccentric jet directed towards the anterior mitral leaflet. Slope of the jet of very pronounced aortic insufficiency and holodiastolic inversion of the flow in the descending aorta, compatible with severe aortic insufficiency. Other findings superimposed on those reported in the transthoracic echocardiogram.

Diagnosis
Heart failure triggered by respiratory infection, in a patient with severe aortic valve disease (severe aortic insufficiency due to flail of one of the leaflets).
