HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
A 63-year-old man, operated in 1986 for ascending thoracic aortic aneurysm and severe aortic insufficiency secondary to bicuspid aortic valve. He underwent Bentall-Bono surgery with implantation of a bicuspid aortic valve prosthesis
Bono surgery was performed with implantation of a mechanical prosthesis. As a complication, he presented with extensive anteroseptal infarction after the patient was taken off cardiopulmonary bypass, which led to severe systolic dysfunction with a left ventricular ejection fraction (LVEF) of 30%.
The patient has remained asymptomatic ever since.
Treatment: lisinopril 5 mg/24 hours, acenocoumarol, atorvastatin 20 mg/24 hours, bisoprolol 2.5 mg/24 hours, spironolactone 25 mg/24 hours.

Present illness
The patient came for consultation because for the last 6 months he has presented with moderate exertional dyspnoea not previously present. He does not report chest pain or increased oedema in the lower limbs or any other symptoms compatible with heart failure.
He also reported the appearance of a lump in the upper third of the sternum, without skin opening, fever or redness in the area.

Physical examination
Cardiac auscultation: rhythmic, aortic prosthetic sounds. Systolic murmur II/VI in mitral focus.
Pulmonary auscultation: preserved vesicular murmur. No crackles.
Lump at the level of the upper third of the sternotomy next to the sternal notch, on the right edge of the sternum. No redness or increase in temperature. No clear signs of infection. Liquid content to the touch. The presence of thrill on auscultation and to the touch is striking. Not painful.

COMPLEMENTARY TESTS
Electrocardiogram (ECG): sinus rhythm. Left bundle branch block with secondary repolarisation alterations.
Echocardiogram: dilated left ventricle (LV) with severely depressed LVEF. Extensive anterior, anteroseptal and septal akinesia. Moderate functional mitral insufficiency (MI).
Aortic prosthesis with no evidence of dysfunction. Right ventricle (RV) of normal size and function.
No tricuspid insufficiency (TI) that would allow estimation of pulmonary systolic pressure.
Transesophageal echocardiogram focused on assessing mitral insufficiency: moderate functional mitral insufficiency (MI) (effective regurgitant orifice (ERO) 2D 0.12 cm2, area of vena contracta 3D 0.15 cm2). Anatomy suitable for mitral clip implantation. Aortic valved tube with no evidence of dysfunction.
Given the findings of the physical examination in relation to the bultoma, it was decided to request a CT scan of the aorta to rule out vascular complications at this level.
The CT scan showed a skin lesion in the anterior mediastinal region, in contact with the ascending thoracic aorta through a bone defect in the sternal manubrium. However, there is no contrast in its interior so it should not have flow in the arterial phase. Chronic dissections are seen in the intervened ascending aorta, one of them with a connection to the cutaneous lesion.

CLINICAL EVOLUTION
Given the presence of pseudoaneurysm contained in the valved tube, it was decided to perform repair surgery. Prior to surgery, a transeophageal echocardiogram was performed to confirm the severity of the MR, coronary artery catheterisation was also performed, which ruled out the presence of lesions, and the presence of double lumen in the valved tube was confirmed by aortography. It was jointly decided that as the patient was going to undergo cardiac surgery, he would benefit from mitral valvuloplasty with a ring.
Surgery was performed with hypothermic arrest at 18o given the high risk of rupture of the pseudoaneurysm when performing the sternotomy. The pseudoaneurysm was confirmed with an entry port at the anastomosis of the valved tube with the aortic root. It is completely removed and replaced with a biological valved tube. Ring annuloplasty is also performed. Postoperative period was uneventful.
One year later, a control echocardiogram showed: aortic prosthesis with no evidence of dysfunction, mitral annuloplasty with significant MR that was difficult to quantify, dilated LV with severely depressed LVEF (30%) and akinesia of the anterior, anteroseptal and septal faces.
Transesophageal echocardiography was then requested to quantify the MR, which showed: mitral annuloplasty with severe functional MR (ORE 2D 0.34 cm2). Dehiscence of the mitral annulus between 7 and 9 o'clock in surgical position, leaving a communication between the upper and lower part of the annulus of 1.68 cm2. Biological aortic prosthesis and aortic tube with no evidence of dysfunction. Rest of the study superimposable to previous ones.
Given that the patient was asymptomatic for the moment, it was decided to maintain a wait-and-see attitude with regard to mitral insufficiency.
In March 2020, the patient was diagnosed with bilateral SARS-CoV-2 coronavirus pneumonia. During his admission, the patient developed respiratory distress syndrome and was admitted to the intensive care unit (ICU), requiring invasive mechanical ventilation. After 12 days in the ICU, the patient evolved correctly and was extubated and transferred to the ward, where he is currently progressing favourably.

DIAGNOSIS
Bicuspid aortic valve.
Ascending aortic aneurysm.
Bentall-Bono surgery with implantation of mechanical aortic prosthesis.
Type V myocardial infarction in relation to surgery.
Heart failure with severely depressed LVEF.
Pseudoaneurysm of valved aortic tube.
Severe functional mitral regurgitation.
New Bentall-Bono surgery with implantation of a biological aortic prosthesis.
Dehiscence of mitral valvuloplasty ring with severe residual MR.
Severe bilateral SARS-CoV-2 pneumonia.
