Chest Tightness\Aortic Replacement\No Improvement in Chest Tightness

Female, 82 years old Outpatient record Department: Cardiac Surgery June 16, 15:23 Chief complaint: Follow-up of ascending aortic dilatation History of present illness: The patient reported chest tightness and discomfort and came for evaluation. Echocardiography showed 1. bicuspid aortic valve with calcification and mild stenosis, and aneurysmal dilatation of the ascending aorta; 2. basal septal hypertrophy. Physical examination: Heart rate bpm, regular rhythm, general condition fair. Outpatient diagnosis: Ascending aortic dilatation Management: 1. Regular follow-up and re-examination 2. Further investigations 3. Medication regimen Print time: June 16, 15:33

Echocardiography report (Transthoracic echocardiography + left ventricular function assessment + TDI) Parasternal long-axis; parasternal short-axis; apical views I. M-mode and Doppler measurements: /mmHg (H(cm):/W(kg):/BSA:/) Measurement Normal range Aortic root diameter 36 (23-36 mm) Left atrial diameter 33 (23-39 mm) Left ventricular end-diastolic diameter 45 (37-54 mm) Left ventricular end-systolic diameter 28 (21-35 mm) Interventricular septal thickness 12 (6-11 mm) Left ventricular posterior wall thickness 11 (6-11 mm) Pulmonary artery systolic pressure 32 (<40 mmHg) II. Left ventricular function and tissue Doppler imaging Left ventricular ejection fraction (LVEF): 68% Mitral valve flow: EA double peak, E/A <0.8; DT: 210 ms DTI: S-wave peak 8 cm/s; e'/a' <1 III. Two-dimensional echocardiography and blood flow imaging of cardiac chambers and great vessels: 1. Normal left atrial and left ventricular dimensions. Basal septal hypertrophy present. Other left ventricular wall thicknesses normal. No abnormality in left ventricular outflow tract. Normal segmental left ventricular wall motion. 2. Mitral valve not thickened, leaflets open normally, valve area within normal range, leaflet coaptation normal. Color Doppler shows mild mitral regurgitation. 3. Aortic sinuses not dilated. Ascending aorta shows aneurysmal dilatation measuring 53 mm. Bicuspid aortic valve with transverse raphe and ridge at the left-right coronary commissure. Valve calcified with mildly restricted opening. Continuous-wave Doppler: peak velocity 2.8 m/s, peak gradient 28 mmHg, mean gradient 16 mmHg. Color Doppler shows mild aortic regurgitation. 4. Inferior vena cava diameter normal. No abnormal echoes in right heart chambers. No atrial septal defect. No interatrial shunt on color Doppler. Normal right atrial diameter. Normal right ventricular basal diameter, outflow tract diameter, and wall thickness. Normal right ventricular systolic function with normal TAPSE. Pulmonary artery not dilated. Pulmonary valve not thickened, opens normally. Tricuspid valve not thickened, leaflets open and coapt normally. Color Doppler shows mild tricuspid regurgitation. 5. No significant pericardial effusion. IV. Conclusion: Outpatient diagnosis: Bicuspid aortic valve with calcification and mild stenosis, aneurysmal dilatation of the ascending aorta; basal septal hypertrophy Examination time: June 16, 14:14:37 Verification time: June 16, 14:24:57

Informed consent for implantable medical device September 11, 16:05 Admission diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; NYHA Class III heart failure Implantable medical device to be used during treatment: artificial vascular graft, wire, etc. The attending physician has explained the details clearly to the patient and family, who indicate understanding and consent to implantation of the device. Patient opinion: (“Agree” or “Disagree” with treatment): √ Agree □ Disagree

September 11, 16:01 Surgical consent form Proxy name: (omitted) Relationship to patient: Husband Discussion record: 1. Diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; NYHA Class III heart failure 2. Surgical indications: Ascending aortic aneurysm, congenital bicuspid aortic valve deformity, NYHA Class III heart failure 3. Proposed procedure: Partial resection of ascending aorta with artificial vascular graft replacement + partial aortic arch artificial vascular graft replacement + transesophageal echocardiography + open-heart surgery with cardiopulmonary bypass + open-heart surgery under hypothermia 4. Proposed anesthesia: General anesthesia 5. Surgical risks and complications: Possible intraoperative and postoperative complications and risks include: 1. Anesthesia accident; 2. Cardiopulmonary bypass accident (blood or air embolism, heart-lung machine malfunction, etc.); 3. Intraoperative or postoperative major bleeding, pericardial tamponade, re-exploration for hemostasis, uncontrollable bleeding, etc.; 4. Difficulty weaning from cardiopulmonary bypass, low cardiac output syndrome, or cardiac arrest with failure to resuscitate; 5. Intraoperative or postoperative electrolyte imbalance, arrhythmia; 6. Embolism of organs or limbs due to blood or air emboli or other causes, potentially leading to gangrene; 7. Postoperative failure of major organs including heart, lung, brain, liver, or kidney; 8. Prolonged mechanical ventilation leading to pulmonary complications, or tracheostomy with failure to wean from ventilator; 9. Conduction system injury causing severe conduction block requiring permanent pacemaker implantation; 10. Paravalvular leak (possible reoperation for repair or valve replacement); 11. Residual shunt; 12. Persistent murmur postoperatively; 13. Valve dysfunction after repair or prosthetic valve dysfunction; 14. Reocclusion after coronary bypass, perioperative myocardial infarction, aortic dissection after bypass; 15. Infection including endocarditis, wound infection, sternal dehiscence, pneumonia, 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 management If the patient or proxy does not fully understand the above risks and complications, they may consult the physician. After full understanding, the patient or proxy may independently decide whether to proceed with surgery or choose alternative treatment. Please indicate your decision and sign below.

Intraoperative transesophageal echocardiography report Instrument: Portable echocardiography Examination: Intraoperative transesophageal echocardiography and three-dimensional echocardiography I. Echocardiographic findings (good acoustic window): Preoperative transesophageal echocardiography: 1. Normal left atrial and left ventricular dimensions. Basal septal hypertrophy present. Other left ventricular wall thicknesses normal. Normal left ventricular outflow tract. Normal segmental left ventricular wall motion. 2. Mitral valve not thickened, leaflets open normally, valve area within normal range, leaflet coaptation normal. Color Doppler shows mild mitral regurgitation. 3. Aortic sinuses not dilated. Ascending aorta shows aneurysmal dilatation measuring 53 mm. Bicuspid aortic valve with transverse raphe and ridge at left-right coronary commissure. Valve calcified with mildly restricted opening. Continuous-wave Doppler: peak velocity 2.8 m/s, peak gradient 28 mmHg, mean gradient 16 mmHg. Color Doppler shows mild aortic regurgitation. 4. Inferior vena cava diameter normal. No abnormal echoes in right heart chambers. No atrial septal defect. No interatrial shunt on color Doppler. Normal right atrial diameter. Normal right ventricular basal diameter, outflow tract diameter, and wall thickness. Normal right ventricular systolic function with normal TAPSE. Pulmonary artery not dilated. Pulmonary valve not thickened, opens normally. Color Doppler shows mild pulmonary regurgitation. Tricuspid valve not thickened, leaflets open and coapt normally. Color Doppler shows mild tricuspid regurgitation. 5. No significant pericardial effusion. Intraoperative transesophageal echocardiography: After ascending aortic replacement, the graft appears normal. Aortic valve remains bicuspid with transverse raphe and ridges at the commissures. Leaflets thickened with mildly restricted opening. Continuous-wave Doppler: peak gradient 11 mmHg, mean gradient 7 mmHg. Leaflet coaptation normal. Color Doppler shows mild aortic regurgitation. II. Conclusion: Intraoperative transesophageal echocardiography: (Preoperative) Bicuspid aortic valve with calcification and mild stenosis, aneurysmal dilatation 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

Chest X-ray report Department: Cardiac Surgery Clinical diagnosis: Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; NYHA Class III heart failure Indication: Postoperative follow-up Examination time: September 14, 13:23:55 Report time: September 15, 09:10:18 Verification time: September 15, 10:30:20 Examination: Chest, posteroanterior view Findings: Post-cardiac surgery changes with dense sternal suture material. Increased pulmonary markings bilaterally with scattered linear and patchy opacities. Heart shadow slightly enlarged. Mediastinum slightly widened. Diaphragms smooth. Costophrenic angles blunted. Impression: Postoperative cardiac surgery changes, bilateral pulmonary exudates, small bilateral pleural effusions. Similar to prior study of September 13. Recommend follow-up. Heart shadow slightly enlarged; please correlate with echocardiography.

(Additional similar chest X-ray reports on September 13, 15, and 18 showing comparable postoperative findings with persistent mild pleural effusions and slightly enlarged cardiac silhouette.)

Pathology report Department: Cardiac Surgery Specimen: Ascending aortic wall tissue Received: September 13, 07:47:27 Verified: September 17, 13:09:23 Gross: Tubular wall tissue, 3.8 × 1.4 cm, wall thickness 0.2 cm. Diagnosis: Elastic arterial wall with mild mucoid degeneration of the media; otherwise unremarkable.

Postoperative echocardiography (September 18) (Transthoracic echocardiography + left ventricular function assessment + TDI) Findings: Ascending aorta replaced with 30 mm graft, no abnormality. Bicuspid aortic valve with calcification, opening unrestricted. Mild aortic regurgitation. LVEF 66%. No significant pericardial effusion. Conclusion: 1. No abnormality after ascending aortic replacement 2. Bicuspid aortic valve deformity

Discharge summary Department: Cardiac Surgery Admission: September 10 Discharge: September 20 [Outpatient diagnosis] Ascending aortic aneurysm; congenital bicuspid aortic valve deformity; NYHA Class III heart failure; hyperlipidemia [Admission diagnosis] Same as above [Discharge diagnosis] Status post vascular graft replacement [Admission findings] Ascending aortic dilatation discovered on routine examination 5 years earlier. Normal chest wall. Clear lung fields on percussion. Normal cardiac apex. Heart rate 76 bpm, regular rhythm. No peripheral signs of aortic regurgitation. [Pathology] Mild mucoid degeneration of aortic media. [Key laboratory results] Various abnormalities noted including elevated white blood cell count, elevated NT-proBNP, mild renal impairment, and anticoagulation parameters consistent with warfarin therapy. [Special investigations] Preoperative CTA confirmed ascending aortic aneurysm. Multiple postoperative chest radiographs showed expected changes with small pleural effusions. [Course] Surgery performed on September 12: Partial ascending aortic resection with graft replacement and partial aortic arch replacement under cardiopulmonary bypass and hypothermia. Coronary angiography showed mild coronary disease. [Discharge status] Alert, stable vital signs. Heart rate 90 bpm, regular rhythm, no murmur. No lower extremity edema. Discharge medications: Torasemide 5 mg once daily (1 month) Metoprolol succinate extended-release 0.5 tablet once daily (1 month) Pentoxyverine 1 tablet three times daily (1 month) Warfarin sodium 1.5 mg once daily (4 months, with INR monitoring target 2.0-3.0) Pantoprazole 20 mg once daily (until finished) Urapidil extended-release 30 mg once daily (until finished, monitor blood pressure) [Discharge instructions] Keep wound clean and dry. Suture removal in two weeks. Avoid heavy lifting for six months. Gradual rehabilitation. Monitor heart rate, blood pressure, and symptoms. [Treatment outcome] Cured [Follow-up plan] Scheduled visits in early October with blood tests, ECG, chest X-ray, etc.

Hospital B discharge summary Department: Cardiovascular Medicine … Subsequent records from October showed persistent atrial fibrillation episodes, mild pleural and pericardial effusions, and ongoing mild aortic valve dysfunction on follow-up echocardiography. No significant improvement in symptoms noted.