ABC | Volume 112, Nº2, February 2019

Anatomopathological Correlation Case 1/2019 – A 51-year-old Man with Arterial Hypertension, Aortic Dissection and Aortic Valve Regurgitation, in Addition to Heart Failure with Unchanged Clinical Course After Surgical Intervention Desiderio Favarato and Vera Demarchi Aiello Instituto do Coração (Incor) - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP – Brazil Mailing Address: Vera Demarchi Aiello • Avenida Dr. Enéas de Carvalho Aguiar, 44, subsolo, bloco I, Cerqueira César. Postal Code 05403-000, São Paulo, SP – Brazil E-mail: demarchi@cardiol.br , anpvera@incor.usp.br Keywords Hypertension; Aortic Valve Insufficiency; Aortic Aneurysm/ surgery; Aneurysm, Dissecting/surgery; Heart Failure. Section Editor: Alfredo José Mansur (ajmansur@incor.usp.br ) Associated editors: Desidério Favarato (dlcfavarato@incor.usp.br ) Vera Demarchi Aiello (anpvera@incor.usp.br ) DOI: 10.5935/abc.20190013 A 51-year-old male, hypertensive patient, a former smoker, was transferred for treatment of thoracic aortic dissection and heart failure. After a three-week period with progressively more intense chest pain, accompanied by dyspnea, sweating and vomiting, he was admitted to the Hospital in the city where he lived. At hospital admission, he had high blood pressure and the diagnosis of thoracic aortic dissection was made. He received antihypertensive and beta-blocker medications. On the fifth day, he was transferred to Instituto do Coração for treatment. At that moment, he was asymptomatic. The physical examination (June 14, 2012) showed good general health status, paleness, ++ / 4+, increased jugular venous pressure, heart rate of 80 bpm, blood pressure 80 x 60 mmHg; clear lungs; cardiac auscultation disclosed rhythmic heart sounds and ++++ diastolic murmur on the left sternal border, no abdominal alterations, lower limbs without edema, besides palpable and symmetrical pulses. Laboratory tests (June 14, 2012) showed hemoglobin 15.9 g/dL; hematocrit, 49%; leukocytes, 10,080/mm³ (neutrophils 64%, eosinophils 7%, lymphocytes 21%, and monocytes 8%); platelets 232,000/mm³; CKMB, 1.33 ng/mL; troponinI,0.106ng/mL;urea,38mg/dL;creatinine,0.94mg/dL; sodium, 137 mEq/L; potassium, 4.2 mEq/L; prpthrombin time (PT) (INR), 1.1; APTT time ratio, 0.78; AST, 30 U/L; ALT, 61 U/L; gamma-GT, 116 IU/L; alkaline phosphatase, 81 U/L; and negative serology for hepatitis B, C, and HIV. The electrocardiogram (ECG) performed on June 16, 2012 showed sinus rhythm, left atrial and left ventricular overload with strain pattern (Figure 1). The echocardiogramperformed on June 17, 2012, disclosed the following measurements: aorta, 37mm; left atrium, 48mm; septal thickness and posterior wall, 9 mm; left ventricle, 87/78 mm; ejection fraction, 22%. The patient showed eccentric hypertrophy with diffuse hypokinesis; moderatemitral regurgitation; marked aortic regurgitation; ascending aortic dissection was observed, with the original intimal tear 25 mm from the valve plane. The aortic measurements at the different levels were: aortic sinus, 37 mm, sinotubular junction, 46 mm, ascending aorta, 67 mm and aortic arch, 34 mm. The posteroanterior chest X-ray performed on June 18, 2012 showed normal lung fields, aorta with an image suggestive of aneurysm, and enlarged cardiac area (Figure 2) The coronary angiography did not show any coronary lesions. The pressures were: aorta: (syst/diast/mean) 100/50/67 mmHg and left ventricular: (Syst/initial diast/end diast) 100/10/20 mmHg. The left ventricle showed diffuse hypokinesis. There was marked aortic regurgitation and an ascending aortic aneurysm, with an image suggestive of dissection (Figure 3). The patient underwent surgery for repair of the ascending aortic dissection, with the interposition of a Dacron tube and aortic valve repair (June 19, 2012). The postoperative period was uneventful, and the patient was discharged on the ninth postoperative day. Almost a month after hospital discharge (July 11, 2012), he sought emergency medical attention for worsening of dyspnea, attributed to non-adherence to the prescribed medication. The physical examination (July 11, 2012) disclosed a heart rate of 60 bpm, blood pressure 80 x 60 mmHg; clear lungs; normal cardiac auscultation, no abdominal alterations; lower limbs without edema and no signs of deep vein thrombosis, with normal pulses. The laboratory tests (July 18, 2012) showed hemoglobin 10.7 g/dL; hematocrit, 32%; leukocytes, 9,750/mm³ (band cells 1%, segmented 69%, eosinophils 8%, basophils 3%, lymphocytes 14%, monocytes 5%), platelets, 443,000/mm³, C-reactive protein, 65.05 mg/L; urea 29 mg/dL; creatinine, 0.90 mg/dL, sodium, 130 mEq/L; potassium, 4.8 mEq/L; magnesium, 1.70 mEq/L, BNP, 1280 pp / mL, venous lactate 21 mg/dL; venous gasometry: pH 7.38, pCO 2 , 48 mmHg; pO 2 , 34.9 mmHg, O 2 saturation, 53.8%; bicarbonate, 26.5 mEq/L, base excess, 2 mEq/L. Blood, urine and catheter tip cultures were negative. One month after this episode he was again brought to emergency care (August 11, 2012) with dyspnea on minimal exertion, orthopnea andoliguria for twodays.Hedeniedcoughing, fever, coryza or diarrhea; chest pain or palpitation. He reported correct use of medications and hydrosaline restriction. The physical examination on admission showed blood pressure of 80x60 mmHg, heart rate of 102 bpm, fine pulses and decreased peripheral perfusion; jugular venous pulse was present; rhythmic heart sounds, presence of third heart 204