Detailed Treatment Process
Female, 82 years old Medical record Department: Cardiac Surgery June 16, 15:23 Chief complaint: Follow-up for ascending aortic dilation History of present illness: The patient presented with chest tightness and discomfort for follow-up. Echocardiography showed 1. bicuspid aortic valve with valvular calcification and mild stenosis, aneurysmal dilation of the ascending aorta 2. basal septal hypertrophy Physical examination: HR bpm, regular rhythm, general condition fair. Outpatient diagnosis: Ascending aortic dilation Management: 1. Follow-up with regular re-examination 2. Examinations 3. Medication plan Print time: June 16, 15:33
Echocardiographic Diagnostic Report (Cardiac Color Doppler Ultrasound + Left Heart Function Measurement + TDI) Parasternal long axis; parasternal short axis; apical views I. M-mode and Doppler flow ultrasound measurements: /mmHg (H(cm):/W(kg):/BSA:/) Item Measured value Normal value Aortic root diameter 36 (23-36mm) Left atrial diameter 33 (23-39mm) Left ventricular end-diastolic diameter 45 (37-54mm) Left ventricular end-systolic diameter 28 (21-35mm) Interventricular septum thickness 12 (6-11mm) Left ventricular posterior wall thickness 11 (6-11mm) Pulmonary artery systolic pressure 32 (<40mmHg) II. Left heart function measurement and tissue Doppler imaging Left ventricular ejection fraction (LVEF): 68% Mitral valve flow pattern: EA double peak, E/A<0.8; DT: 210 ms DTI showed S wave peak: 8 cm/s; e'/a'<1 III. Standard two-dimensional echocardiography and blood flow imaging of cardiac chambers and great vessels: 1. Normal left atrial diameter, normal left ventricular diameter, basal septal hypertrophy, normal thickness of other left ventricular walls, no abnormality in left ventricular outflow tract, normal segmental left ventricular systolic function. 2. Mitral valve not thickened, leaflets open without restriction, valve area within normal range, normal leaflet coaptation, color Doppler shows mild mitral regurgitation. 3. Aortic sinus not dilated, ascending aorta shows aneurysmal dilation measuring 53mm, bicuspid aortic valve with transverse raphe and ridge at left-right coronary commissure, valvular calcification, mildly restricted opening, CW estimated peak velocity 2.8m/s, peak pressure gradient 28mmHg, mean pressure gradient 16mmHg, color Doppler shows mild aortic regurgitation. 4. Normal inferior vena cava diameter, no abnormal echoes in right heart chambers, no echo dropout in atrial septum, color Doppler shows no atrial-level shunt. Normal right atrial diameter, normal right ventricular basal diameter, normal right ventricular outflow tract diameter, normal right ventricular wall thickness, normal right ventricular systolic function, normal TAPSE. Pulmonary artery not dilated, pulmonary valve not thickened, opens without restriction, pulmonary artery mean pressure not measured, tricuspid valve not thickened, leaflets open without restriction, normal leaflet coaptation, color Doppler shows mild tricuspid regurgitation. 5. No significant pericardial effusion. IV. Conclusion: Outpatient diagnosis: Bicuspid aortic valve with valvular calcification and mild stenosis, aneurysmal dilation of the ascending aorta; basal septal hypertrophy Examination time: June 16, 14:14:37 Verification time: June 16, 14:24:57
Informed Consent Form for Use of Implantable Medical Devices September 11, 16:05 Admission diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III Implantable medical devices to be used during treatment: artificial vascular graft, steel wire, etc. The attending physician has explained clearly to the patient and family members. The patient and family members indicate understanding and agree to implantation of the medical device in the patient. Patient opinion: (“Agree” or “Disagree” to treatment): √ Agree □ Disagree
September 11, 16:01 Surgical Treatment Consent Form Agent name: (omitted) Relationship to patient: Husband Discussion record: 1. Patient diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III 2. Surgical indications: Ascending aortic aneurysm, congenital bicuspid aortic valve deformity, cardiac function class III 3. Planned procedure: Partial resection of ascending aorta with artificial vascular graft replacement + partial aortic arch artificial vascular graft replacement + transesophageal echocardiography + cardiopulmonary bypass-assisted open heart surgery + open heart surgery under hypothermia (systemic) 4. Planned anesthesia: General anesthesia 5. Surgical risks and complications: Possible intraoperative and postoperative complications and surgical risks: 1. Anesthesia accident; 2. Cardiopulmonary bypass accident (blood or air embolism, artificial heart-lung machine failure, etc.); 3. Intraoperative or postoperative major bleeding, pericardial tamponade, re-thoracotomy for hemostasis, uncontrolled bleeding, etc.; 4. Difficulty in cardiac resuscitation, low cardiac output syndrome, or cardiac arrest with failure to resuscitate; 5. Intraoperative or postoperative electrolyte disturbance, arrhythmia; 6. Organ embolism or limb embolism and gangrene due to blood or air embolism or other causes; 7. Postoperative failure of major organs including heart, lung, brain, liver, kidney, etc.; 8. Pulmonary complications due to prolonged postoperative ventilator use, or tracheostomy with failure to wean from ventilator; 9. Conduction system injury leading to severe conduction block requiring permanent pacemaker implantation; 10. Paravalvular leak (possible reoperation for repair or valve replacement); 11. Residual shunt; 12. Possible residual murmur postoperatively; 13. Valve dysfunction after repair or prosthetic valve dysfunction; 14. Reocclusion after coronary artery bypass grafting, perioperative myocardial infarction, aortic dissection after bypass grafting; 15. Infection such as endocarditis, wound infection, sternal dehiscence, pulmonary infection, urinary tract infection, etc.; 16. Other complications such as upper gastrointestinal bleeding, local puncture site bleeding, hemopneumothorax, hoarseness; 17. Anticoagulation-related complications after valve replacement (bleeding, thrombosis, etc.); 6. Alternative treatment: Medical drug therapy If the patient or agent does not understand the above surgical risks and complications, they may consult the physician. After full understanding, the patient or agent shall independently decide whether to proceed with surgery or opt for alternative medical treatment. Please state your opinion and sign on this form.
Echocardiographic Diagnostic Report Instrument: Portable echocardiography Examination items: () Intraoperative transesophageal echocardiography and three-dimensional echocardiography I. Echocardiographic findings: (Acoustic window: good) Preoperative transesophageal echocardiography: 1. Normal left atrial diameter, normal left ventricular diameter, basal septal hypertrophy, normal thickness of other left ventricular walls, no abnormality in left ventricular outflow tract, normal segmental left ventricular systolic function. 2. Mitral valve not thickened, leaflets open without restriction, valve area within normal range, normal leaflet coaptation, color Doppler shows mild mitral regurgitation. 3. Aortic sinus not dilated, ascending aorta shows aneurysmal dilation measuring 53mm, bicuspid aortic valve with transverse raphe and ridge at left-right coronary commissure, valvular calcification, mildly restricted opening, CW estimated peak velocity 2.8m/s, peak pressure gradient 28mmHg, mean pressure gradient 16mmHg, color Doppler shows mild aortic regurgitation. 4. Normal inferior vena cava diameter, no abnormal echoes in right heart chambers, no echo dropout in atrial septum, color Doppler shows no atrial-level shunt. Normal right atrial diameter, normal right ventricular basal diameter, normal right ventricular outflow tract diameter, normal right ventricular wall thickness, normal right ventricular systolic function, normal TAPSE. Pulmonary artery not dilated, pulmonary valve not thickened, opens without restriction, color Doppler shows mild pulmonary regurgitation, tricuspid valve not thickened, leaflets open without restriction, normal leaflet coaptation, color Doppler shows mild tricuspid regurgitation. 5. No significant pericardial effusion. Intraoperative transesophageal echocardiography: After ascending aortic replacement, artificial vascular graft appears normal. Aortic valve shows bicuspid transverse raphe with left-right commissural ridge, thickened leaflets, mildly restricted opening, continuous-wave Doppler estimated peak pressure gradient 11mmHg, mean pressure gradient 7mmHg, normal leaflet coaptation, color Doppler shows mild aortic regurgitation. II. Conclusion: Intraoperative transesophageal echocardiography: (Preoperative) bicuspid aortic valve with valvular calcification and mild stenosis, aneurysmal dilation of the ascending aorta; (Postoperative) no abnormality after ascending aortic replacement (Report for reference only; please correlate with clinical findings) Examination time: September 12, 16:40:34 Verification time: September 12, 16:40:34
Radiology Diagnostic Report (X-ray) Department: Cardiac Surgery Clinical diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III Request from referring physician: Postoperative follow-up Examination time: September 14, 13:23:55 Report writing time: September 15, 09:10:18 Report verification time: September 15, 10:30:20 Examination site and name: Chest Examination method: Chest PA view Radiographic findings: Post-cardiac surgery, dense suture lines in sternal area, increased lung markings bilaterally, scattered linear and patchy opacities in both lungs, slightly enlarged cardiac silhouette, mildly widened mediastinum, smooth diaphragmatic surfaces, blunted costophrenic angles bilaterally. Radiological diagnosis: (Bedside) Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions, overall similar to previous film of 25-09-13, follow-up recommended; slightly enlarged cardiac silhouette, please correlate with echocardiography.
Radiology Diagnostic Report (X-ray) Department: Cardiac Surgery Clinical diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III Request from referring physician: Assistance Examination time: September 13, 13:25:25 Report writing time: September 13, 16:33:03 Report verification time: September 15, 08:38:51 Examination site and name: Chest Examination method: Chest PA view Radiographic findings: Post-cardiac surgery, dense suture lines in sternal area, increased lung markings bilaterally, scattered linear and patchy opacities in both lungs, slightly enlarged cardiac silhouette, mildly widened mediastinum, smooth diaphragmatic surfaces, blunted costophrenic angles bilaterally. Radiological diagnosis: Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions, follow-up recommended; slightly enlarged cardiac silhouette, please correlate with echocardiography.
Department: Cardiac Surgery Clinical diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III Request from referring physician: Assistance Examination time: September 15, 13:51:41 Report writing time: September 15, 14:55:23 Report verification time: September 16, 07:55:56 Examination site and name: Chest Examination method: Chest PA view Radiographic findings: Post-cardiac surgery, dense suture lines in sternal area, increased lung markings bilaterally, scattered linear and patchy opacities in both lungs, slightly enlarged cardiac silhouette, mildly widened mediastinum, smooth diaphragmatic surfaces, blunted costophrenic angles bilaterally. Radiological diagnosis: (Bedside) Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions, follow-up recommended; slightly enlarged cardiac silhouette, please correlate with echocardiography.
Pathology Diagnostic Report Department: Cardiac Surgery Pathology No.: Specimen submitted: Received time: September 13, 07:47:27 Report verification time: September 17, 13:09:23 Gross description: (Ascending aortic wall tissue) Tubular tissue, 3.8 × 1.4 cm, wall thickness 0.2 cm. Diagnosis: (Ascending aortic wall tissue) Submitted elastic vascular wall with mild mucoid degeneration of the media, otherwise unremarkable. Sampling sites:
Radiology Diagnostic Report (X-ray) Department: Cardiac Surgery Clinical diagnosis: Follow-up after partial ascending aorta and aortic arch artificial vascular graft replacement Request from referring physician: Postoperative follow-up Examination time: September 18, 09:00:35 Report writing time: September 18, 09:15:35 Report verification time: September 18, 11:20:32 Examination site and name: Chest Examination method: Chest PA view Radiographic findings: Post-cardiac surgery, dense suture lines in sternal area, increased lung markings bilaterally, scattered linear and patchy opacities in both lungs, slightly enlarged cardiac silhouette, mildly widened mediastinum, smooth diaphragmatic surfaces, blunted costophrenic angles bilaterally. Radiological diagnosis: Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions; slightly enlarged cardiac silhouette, please correlate with echocardiography.
Echocardiographic Diagnostic Report (Cardiac Color Doppler Ultrasound + Left Heart Function Measurement + TDI) Parasternal long axis; parasternal short axis; apical views; Acoustic window: poor I. Two-dimensional and Doppler ultrasound measurements: /mmHg (H(cm):152 W(kg):/BSA:/) Item Measured value Normal value Aortic root diameter 33 (23-36mm) Left atrial diameter 39 (23-39mm) Left ventricular end-diastolic diameter 47 (37-54mm) Left ventricular end-systolic diameter 30 (21-35mm) Interventricular septum thickness 11 (6-11mm) Left ventricular posterior wall thickness 10 (6-11mm) Pulmonary artery systolic pressure 21 (<40mmHg) II. Left heart function measurement and tissue Doppler imaging: Left ventricular ejection fraction (LVEF): 66% Mitral valve flow pattern: Single peak, irregular rhythm, E/A/0.8; DT:/ms DTI showed S wave peak: 5 cm/s; e'/a'/1 III. Standard two-dimensional echocardiography and blood flow imaging of cardiac chambers and great vessels: 1. Normal left atrial diameter, normal left ventricular diameter, normal left ventricular wall thickness, no abnormality in left ventricular outflow tract, normal segmental left ventricular systolic function. 2. Mitral valve not thickened, leaflets open without restriction, valve area within normal range, normal leaflet coaptation, color Doppler shows no mitral regurgitation. 3. Aortic sinus not dilated, no abnormality after ascending aorta artificial vascular graft (inner diameter 30mm) replacement, bicuspid aortic valve with transverse raphe and peak at left-right coronary commissure, valvular calcification, opens without restriction, color Doppler shows mild aortic regurgitation. 4. Normal inferior vena cava diameter, no abnormal echoes in right heart chambers, no echo dropout in atrial septum, color Doppler shows no atrial-level shunt. Normal right atrial diameter, normal right ventricular basal diameter, normal right ventricular outflow tract diameter, normal right ventricular wall thickness, normal right ventricular systolic function, normal TAPSE. Pulmonary artery not dilated, pulmonary valve not thickened, opens without restriction, pulmonary artery mean pressure not measured, tricuspid valve not thickened, leaflets open without restriction, normal leaflet coaptation, color Doppler shows mild tricuspid regurgitation. 5. No significant pericardial effusion. IV. Conclusion: 1. No abnormality after ascending aortic replacement 2. Bicuspid aortic valve deformity (Report for reference only; please correlate with clinical findings) Examination time: September 18, 09:05:36 Verification time: September 18, 09:11:01
Discharge Summary Department: Cardiac Surgery Admission date: September 10 Discharge date: September 20 [Outpatient diagnosis] Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III; hyperlipidemia [Admission diagnosis] Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; cardiac function class III; hyperlipidemia [Discharge diagnosis] Status post vascular graft replacement [Admission status (main symptoms and signs)] Physical examination revealed ascending aortic dilation for 5 years. Normal chest contour, clear percussion note over both lungs. No apex impulse elevation, normal apex beat location, no thrill at apex, no pericardial rub, no heaving impulse, no heaving impulse below xiphoid, non-diffuse impulse. Heart rate 76 beats/min, regular rhythm. No water-hammer pulse, no pistol-shot sound, no peripheral capillary signs. [Pathological diagnosis] (Ascending aortic wall tissue) Submitted elastic vascular wall with mild mucoid degeneration of the media, otherwise unremarkable. [Examination results] Urine test [September 11]: Leukocyte esterase +. Electrolytes [September 16]: Ionized calcium 1.10; phosphorus 0.79 mmol/L. Blood gas analysis [September 18]: Carbon dioxide 22 mmol/L; oxygen saturation 99.2%; oxygen partial pressure 203.00. Complete blood count [September 18]: White blood cell count 13.96 × 10⁹/L; monocyte count 1.17 × 10⁹/L; lymphocyte percentage 15.0%; basophil count 0.10 × 10⁹/L; neutrophil count 10.3 × 10⁹/L; total hemoglobin 113.4 g/L. Cardiac markers [September 18]: N-terminal pro-B-type natriuretic peptide 887.0 pg/mL. Cardiac markers [September 18]: Cardiac troponin T 0.038 ng/mL. Renal function [September 18]: Urea 13.5 mmol/L. Liver function [September 18]: γ-Glutamyl transferase 78 U/L; lactate dehydrogenase 333 U/L; total bilirubin 21.2 μmol/L. Coagulation [September 19]: International normalized ratio 2.94; prothrombin time 34.5 seconds; prothrombin time ratio 2.85; D-dimer 2.10 mg/L; activated partial thromboplastin time 42.4 seconds; fibrinogen 696 mg/dL; activated partial thromboplastin time 24.3 seconds. [Main special examinations and consultations] Abdominal aortic CTA (August 13): Abdominal aortic atherosclerosis, common origin of celiac trunk and superior mesenteric artery, mild plaque with slight luminal narrowing at origins of celiac trunk and proximal superior mesenteric artery; hiatal hernia. Thoracic aortic CTA (August 13): Ascending aortic aneurysm, thoracic aortic atherosclerosis. Chest plain scan (September 11): Small chronic inflammatory nodule in right lung, annual follow-up; scattered chronic inflammation and old lesions in both lungs, follow-up. Aneurysmal dilation of ascending aorta, please correlate with clinical findings. Hiatal hernia. Head plain scan (September 11): Multiple lacunar foci in brain, senile brain, suggest MRI if necessary. Routine ECG (September 11): Sinus rhythm with ST-segment changes (horizontal ST depression 0.5mm in V4-V6 leads) and T-wave changes (flat, low upright or biphasic T waves in leads II, III, aVF, V4-V6). Intraoperative (two-dimensional) transesophageal echocardiography (September 12): Intraoperative transesophageal echocardiography: (Preoperative) bicuspid aortic valve with valvular calcification and mild stenosis, aneurysmal dilation of the ascending aorta; (Postoperative) no abnormality after ascending aortic replacement. Chest PA view (September 13): Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions, follow-up; slightly enlarged cardiac silhouette, please correlate with echocardiography. Chest PA view (September 15): (Bedside) Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions, overall similar to previous September 13 film, follow-up; slightly enlarged cardiac silhouette, please correlate with echocardiography. Chest PA view (September 15): (Bedside) Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions, follow-up; slightly enlarged cardiac silhouette, please correlate with echocardiography. Chest PA view (September 18): Post-cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions; slightly enlarged cardiac silhouette, please correlate with echocardiography. Routine echocardiography (Cardiac Color Doppler Ultrasound + Left Heart Function Measurement + TDI) (September 18): 1. No abnormality after ascending aortic replacement 2. Bicuspid aortic valve deformity. Routine ECG (September 18): Sinus rhythm with T-wave changes (flat, biphasic or shallow inverted T waves in leads with dominant R wave). [Course of treatment (surgical procedure, date, transfusion volume, detailed pathology, wound healing and others)] Surgery date: September 12 Intraoperative diagnosis: Ascending aortic aneurysm, congenital bicuspid aortic valve deformity, cardiac function class III Procedure name: Partial resection of ascending aorta with artificial vascular graft replacement, partial aortic arch artificial vascular graft replacement, transesophageal echocardiography, cardiopulmonary bypass-assisted open heart surgery, open heart surgery under hypothermia (systemic) Incision information: Wound class I/healing by first intention Surgical procedure: (1) Patient in supine position, after anesthesia and heparinization, traditional median sternotomy (full sternal split) to expose peripheral vessels and establish cardiopulmonary bypass. (2) Exploration showed ascending aorta diameter of 54mm with dilation visible on the greater curvature. Aortic “I”-shaped incision was made. The diseased ascending aorta was replaced with a 30mm Gelweave straight graft. Proximal anastomosis with continuous 4-0 prolene suture at the sinotubular junction, reinforced with pledgets on inner and outer sides of the graft. Distal anastomosis with continuous 4-0 prolene at the level of innominate artery origin, reinforced with pledgets. Diseased ascending aorta wrapped around the graft with continuous 4-0 prolene. Open distal anastomosis under deep hypothermic circulatory arrest for 13 minutes with innominate artery cerebral perfusion. Surgery time: September 12 Intraoperative diagnosis: Ascending aortic aneurysm, congenital bicuspid aortic valve deformity, cardiac function class III Anesthesia method: Local anesthesia Surgical procedure: Coronary angiography Brief procedure: Coronary angiography: 5F Tig catheter advanced to left coronary ostium showed right-dominant coronary circulation. No stenosis in left main, left anterior descending, first diagonal, left circumflex, or first obtuse marginal branches. 5F Tig catheter advanced to right coronary ostium. Focal 30% stenosis in proximal right coronary artery, focal 40% stenosis in mid right coronary artery. No stenosis in left ventricular posterior branch or posterior descending branch. [Discharge status and discharge orders (medications and recommendations)] The patient was alert with stable vital signs. Clear breath sounds in lungs, heart rate 90 bpm, regular rhythm, no cardiac murmur. No lower limb edema, normal dorsalis pedis pulses. Discharge medications: Torasemide tablets, once daily, 5 mg each time (for 1 month) Metoprolol succinate sustained-release tablets, once daily, 0.5 tablet each time (for 1 month) Pentoxyverine tablets, three times daily, 1 tablet each time (for 1 month) Warfarin sodium tablets, once daily, 1.5 mg each time (for 4 months; decision to discontinue after 4 months based on follow-up; regular prothrombin time monitoring to maintain INR between 2.0-3.0) Aniracetam sodium enteric-coated tablets, once daily, 20 mg each time (until finished) Urapidil sustained-release capsules, once daily, 30 mg each time (until finished, monitor blood pressure) [Discharge instructions] Keep wound clean and dry; remove sutures at the rehabilitation hospital two weeks after surgery Avoid strenuous upper limb activity and lifting objects heavier than 10 kg within six months after surgery Engage in rehabilitation exercise according to improvement in physical capacity Last INR before discharge was 2.94, corresponding to warfarin dose of 1.5 mg; target INR range 2.0-3.0. Take warfarin regularly as prescribed and adjust monitoring based on INR changes with regular coagulation checks Monitor heart rate and blood pressure; seek prompt medical attention for dizziness, presyncope, fatigue, or heart rate below 50 beats/min [Treatment outcome] Cured [Follow-up plan] Follow-up dates: [October 6, Monday afternoon] [October 8, Wednesday morning] [October 10, Friday morning] Tests: Complete blood count, liver and kidney function, electrolytes, cardiac enzymes, ECG, chest X-ray, coagulation profile
Hospital B Discharge Summary Department: Cardiovascular Medicine …… October 15 biochemistry report: Troponin I 0.007 ng/ml, creatine kinase isoenzyme 0.65 ng/ml. October 15 [critical] laboratory report: Prothrombin time PT 34.8S↑, INR 3.19↑, fibrinogen 3.62 g/l, activated partial thromboplastin time 40.50S↑, thrombin time TT 15.70S, antithrombin 126%, fibrin degradation products 3.94 ug/ml. October 15 immunology report: N-terminal pro-brain natriuretic peptide 132.45 pg/ml. October 15 biochemistry report: Potassium 4.12 mmol/l, sodium 142.9 mmol/l, chloride 106.4 mmol/l, calcium 2.35 mmol/l, total protein 70.0 g/l, albumin 42.5 g/l, globulin 27.5 g/l, albumin/globulin ratio 1.55, total bilirubin 9.6 μmol/l, direct bilirubin 1.8 μmol/l, indirect bilirubin 7.8 μmol/l, alanine aminotransferase 9.1 U/l, aspartate aminotransferase 17.9 U/l, γ-glutamyl transferase 26 U/l, total bile acid 1.69 μmol/l, urea 8.34 mmol/l, creatinine 87 μmol/l, uric acid 399 μmol/l↑, glomerular filtration rate 70.86 ml/min/1↓. October 16 [critical] laboratory report: Prothrombin time PT 31.1S↑, INR 2.84↑. September 21 routine ECG: Sinus rhythm, T-wave changes (I, II, III, aVF, V3-V6). September 22 routine ECG: Atrial fibrillation with rapid ventricular rate, ST-T changes (II, III, aVF, V4-V6). September 22 cardiovascular ultrasound: ... external hospital status post partial ascending aorta resection with artificial vascular graft replacement plus partial aortic arch replacement; mild aortic stenosis with mild regurgitation. October 6 other ultrasound: Bilateral pleural effusions, trace pericardial effusion. ... (additional ECG and other records as listed in original)