We present the case of a 68-year-old man with a history of mitro-aortic valve disease who presented with new onset left heart failure, which highlights the importance of finding its cause for its aetiological treatment.

HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION

History
No known drug allergies.
Cardiovascular risk factors (CVRF): arterial hypertension (AHT) of more than 10 years of evolution in treatment with irbesartan with good control. LD of 8 years of evolution.
No diabetes mellitus (DM).
Cardiological history: aortic valve disease of unknown origin (no reports available), which required valve surgery with implantation of a biological aortic prosthesis at the age of 33 (1979), replacement with a BJORK mechanical aortic prosthesis (monodisc no 21) at the age of 43 (1989). And new cardiac surgery for implantation of mechanical mitral prosthesis Omnicarbon No 27 at the age of 55 (2001), due to mitral insufficiency of degenerative origin. Permanent atrial fibrillation (AF) since the age of 53 (cardioversion in 2002, 2003, 2005 not effective). Severe pulmonary hypertension prior to mitral valve surgery. Preserved LVEF.
Other medical history: chronic obstructive pulmonary disease.
Surgical interventions: no other surgical antecedents of interest.
Usual treatment: bromazepam 1.5 mg/24 hours, omeprazole 20 mg/24 hours, irbesartan 150 mg/24 hours, bisoprolol 5 mg/12 hours, furosemide 40 mg/24 hours, digoxin 1.25 mg/24 hours, tadalafil 40 mg/24 hours, paracetamol 1 g/8 hours if needed, sintrom according to guideline.
Baseline: independent for basic activities of daily living. Dyspnoea on moderate exertion. Orthopnoea on 2 pillows. No cognitive impairment.

Present illness
A 68-year-old man with increased dyspnoea of moderate to minimal exertion for 10-12 days. No chest pain. Orthopnoea on 3 pillows. Reduced diuresis.
Increased nocturnal cough without expectoration. Afebrile. Increase in the perimeter of the lower limbs (MMII). Treated with azithromycin and Flutox without improvement. Generalised myalgias.

Physical examination
Blood pressure (BP) 184/85 mmHg, heart rate (HR) 77 bpm, temperature 36 oC, SatO2 91%. Cardiac auscultation: arrhythmic, metallic click in aortic focus, systolic murmur in left parasternal border. Pulmonary auscultation: bilateral crackles with abolition of vesicular murmur in the left hemithorax. Abdomen: RHA+, globular, tympanised, scarcely depressible, not painful on deep palpation. MMII: malleolar oedema with bilateral fovea, chronic venous insufficiency with trophic disorders in the skin.

COMPLEMENTARY TESTS
Chest X-ray: left pleural effusion, image with increased density in the posterior lobe of the right hemithorax, left laminar atelectasis, rounded laminar atelectasis.
Electrocardiogram (ECG): AF with controlled RV. Cornell LVH. Repolarisation alterations in V5, V6, I, aVL, II in digitised patient.
CBC: leukocytes 11,300 thousands/mcl, sodium 68.4%, Hb 12.6 g/dl Hto 39.2%, platelets 179,000 thousands/mcl, urea 81 mg/dl, Cr 1.08 mg/dl, GOT 32 Ul/l, GPT 29 Ul/l, CPK 29, Na 135 mEq/l, K 4.5 mEq/l.
Echocardiogram: severely dilated right atrium. Severely dilated right ventricle. Severe pulmonary hypertension (PHT). RVEF at the limit. Functional tricuspid insufficiency due to dilatation of the annulus and stretching of the chordae tendineae, severe. Slightly dilated left atrium. Anomalous septal motion, paradoxical. Slightly depressed LVEF 45%.
Mitral and aortic metallic prosthesis of monodisc appearance and preserved mobility.
Chest CT: water retention in the right hemithorax (evanescent tumour), a subacute/chronic aortic dissection, Standford type A or type I according to the Bakey classification, without involvement of the coronary arteries.
Abdomen-pelvis CT scan: the dissection extended to the right external iliac artery and reached the right common femoral artery. The true lumen irrigated the celiac trunk, superior and inferior mesenteric artery and both renal arteries. The thoracic portion of the descending aorta had a diameter of 33.4 mm and 26 mm at the level of the diaphragmatic hiatus. The false lumen measured 11.7 mm. There was also a mild right and moderate left pleural effusion of posterobasal and subpulmonary location and a loculated effusion in the right major fissure (evanescent tumour with a smooth and regular edge) measuring 65 x 35 mm.

CLINICAL EVOLUTION
The patient was admitted to hospital for further investigation and treatment. After an initial assessment, the diagnosis was compatible with right and left heart failure, the latter being a new onset, for which diuretic treatment was prescribed. There was clinical improvement and the increase in density found in the X-ray taken during the stay in the emergency department was partially reduced, although it did not disappear. A chest CT scan was requested to assess the image in the right hemithorax, which showed water retention at that level (evanescent tumour) and detected a subacute/chronic aortic dissection of Standford type A or type I according to the Bakey classification, without involvement of the coronary arteries. Subsequent studies showed its extension to the right external iliac artery until it reached the right common femoral artery. The true lumen irrigated the celiac trunk, superior and inferior mesenteric artery and both renal arteries. The patient reported no chest pain at any time.
Given the findings, sintrom was suspended and i.v. sodium heparin was started. The case was discussed with the cardiac surgery service of the referral hospital and it was decided to transfer the patient for surgery.
The patient underwent aortic surgery, implanting a FlowWeave Bioseal 32 mm supracoronary vascular prosthesis, "transforming" the Stanford type A dissection into a type B, together with tricuspid Vega annuloplasty.

DIAGNOSIS
Subacute Stanford type A aortic dissection candidate for cardiac surgery.
Normofunctioning mitral and aortic prosthesis.
Mildly affected LVEF with borderline RVEF.
Severe PHT.
Permanent AF.
AHT.
DLP.
