Ejection Murmur Research Articles

Asymptomatic Coarctation of the Aorta in a Middle-Aged Man; The Significance of Physical Examination

Asymptomatic Coarctation of the Aorta in a Middle-Aged Man; The Significance of Physical Examination

Calcific Aortic Valve Disease

The shifting global demographic profile toward an older population is well recognized and carries with it the increased burden of degenerative cardiovascular disease, with associated morbidity, mortality, and healthcare costs. Vascular ageing is characterized by increased arterial stiffness, systolic arterial hypertension, myocardial thickening and fibrosis, and associated atherosclerosis.1 See Article by Martinsson et al Calcific aortic valve stenosis (CAVS) is another manifestation and affects ≈1 in 30 people aged 75 years. Furthermore, CAVS is associated with several adverse vascular risk factors, including hypertension, hypercholesterolemia, and diabetes mellitus, as well as with underlying structural abnormalities, for example, bicuspid aortic valve. Considerable resources are already devoted to health care consequent on vascular ageing and the load is increasing—as evidenced by the burgeoning need for operative and percutaneous aortic valve replacements.2 If society is to better manage health costs for the older population, we need to better understand the mechanisms of vascular ageing and thereby develop and implement novel preventive strategies. There is significant familial risk for atherosclerotic vascular disease, beyond familial hypercholesterolemia and hypertension, although the actual genetic factors responsible remain elusive. In this issue of Circulation: Cardiovascular Genetics , Martinsson et al3 present evidence for a significant familial risk for CAVS in the general population. At the same time, there is also a lesser, but nonetheless significant, environmental risk. The fascinating question is how we might explain these observations and whether we can now begin to formulate a hypothesis about why some individuals develop CAVS. A systolic ejection murmur is a common finding in older patients and echocardiography has shown us that most individuals develop some thickening and restriction of leaflet motion of the aortic valve with increasing age. Despite this, most …

Abstract P274: Double Hit! A Unique Case of Resistant Hypertension

Case Description: A 52 year-old woman with obesity, HLD, diet-controlled diabetes was referred for resistant hypertension. Her blood pressure (BP) was uncontrolled (systolic 145-200 mmHg, diastolic 95-135 mmHg) on 5 medications. Physical exam revealed a systolic ejection murmur at the base. An ECHO showed normal systolic function and moderate LVH. Plasma aldosterone was 20.7 ng/dL (normal 3-15 g/dL), plasma renin was 0.50 ng/mL/h (normal 0.65-5.0 ng/mL/h), and aldosterone:renin ratio was 41.4 [ng/dL]/[ng/mL/h], meeting criteria for Primary Aldosteronism (PA). Saline infusion test was confirmatory for PA. CT scan of the adrenals did not reveal an adenoma. Subsequent Adrenal Venous Sampling confirmed bilateral Idiopathic Adrenal Hyperplasia (IAH; right and left adrenal vein selectivity index of 42.6, 9.2 respectively; lateralization index was 1.3). She was normokalemic (3.7-4.4 mEq/L), total calcium (Ca) was 11.2 mg/dL (normal Ca 8.0-10.4), and creatinine was 1.4 mg/dL (GFR 47 mL/min/1.73m 2 ). Intact parathyroid hormone (iPTH) was 131.2 pg/mL, phosphorus was 2.4 mg/dL, and 25-hydroxyvitamin D was 30.8 ng/mL, suggesting primary hyperparathyroidism (PPTH). Neck ultrasound was concerning for PTH adenoma and sestamibi scan localized a left adenoma. DXA scan and renal ultrasound were normal. IAH was treated medically with spironolactone. Her BP remained elevated (systolic 138-172 mmHg, diastolic 92-100 mmHg). She underwent parathyroidectomy and histology confirmed an adenoma. Post-operative iPTH and Ca normalized (49.5 pg/mL, 9.7 mg/dL respectively). Postoperative BP measurements improved (systolic 123-138 mmHg, diastolic 75-86 mmHg). Discussion: Evidence shows that a hyperfunctioning parathyroid gland may contribute to maintaining hyperaldosteronism in PA. This is based on in-vitro studies showing PTH increased aldosterone secretion from adrenocortical cells in a concentration dependent manner. Gene expression and immunohistochemistry studies show PTH receptors in aldosterone-producing adenomas and MR receptors in parathyroid cells, suggesting a bi-directional relationship. The significance of this case is in the potential for further understanding of the pathophysiology of common causes of secondary hypertension.

Prevalence and diagnostic characteristics of non-clinical mitral regurgitation murmurs in North American Whippets

ObjectivesTo assess the prevalence of functional ejection murmurs and murmurs of mitral regurgitation (MR) due to myxomatous mitral valve disease in healthy whippets; to assess the diagnostic value of auscultation to detect MR; and investigate the relationship between age and presence of echocardiographically documented MR (MRecho). AnimalsA total of 200 healthy client-owned Whippets, recruited at national shows between 2005 and 2009 were involved in this study. MethodsCross-sectional study. Dogs were examined by auscultation by one examiner and Doppler echocardiography by another, and results were compared. Prevalence of types of murmurs and MRecho were calculated and correlated to age. Accuracy of auscultation to predict MRecho was calculated. ResultsLeft-sided systolic heart murmurs were detected in 185/200 (93%) of dogs. Left apical systolic murmurs (Lapex) were detected in 57/200 (29%) and left basilar systolic murmurs (Lbase) in 128/200 of the dogs (64%). MRecho was present in 76/200 (38%) dogs. Prevalence MRecho was correlated with age (r = 0.96, p=0.0028). Mitral regurgitation detected by echocardiography was present in 12/78 (15%) of the dogs ≤ 2 years of age and in 59% of the dogs at 7–8 years old. Detection of Lapex predicted MRecho with sensitivity 65%, specificity 94%, positive predictive value 86%, and negative predictive value 81%; and accuracy improved when only dogs with more intense Lapex (grade ≥ 3/6) were considered. ConclusionsSystolic murmurs are common in North American Whippets and this breed exhibits a high prevalence of MRecho, which may be documented at a relatively early age. Whippets with non-clinical MRecho may not be identifiable by auscultation alone; echocardiographic examination may be required to exclude a diagnosis of MR. Louder heart murmurs allow more accurate localization in this population.

Bacterial Endocarditis in an Intravenous Drug User with a Ventricular Septal Aneurysm

An aneurysm of the membranous portion of the ventricular septum (AMS) is a common complication of spontaneous ventricular septal defect closure. They have been shown to increase the incidence of cardiac pathology notably bacterial endocarditis. Because of such a severe threat, it may be an important anomaly to assess in high risk patients. A 45-year-old woman with a history of intravenous drug use presented in septic shock with end organ damage requiring intubation, broad spectrum antibiotics, and vasopressors. Physical examination displayed a 2/6 systolic ejection murmur heard loudest at the left lower sternal border. Echocardiography confirmed a mobile tricuspid vegetation; as well as, an aneurysmal deformity. During her initial history the patient stated that her VSD had been diagnosed in childhood. A cardiac catheterization showed a membranous ventricular septal aneurysm protruding from the left ventricle into the right ventricle with no evidence of ventricular septal defect. This case exemplifies a patient predisposed to endocarditis who was at higher risk due to her actions. The objective contribution of the AMS to the resultant endocarditis is unknown at this point. This sentiment raises the question if AMS detection would warrant preventative intervention for associated pathologies.

Accidental Heart Murmurs

Introduction:Accidental murmurs occur in anatomically and physiologically normal heart. Accidental (innocent) murmurs have their own clearly defined clinical characteristics (asymptomatic, they require minimal follow-up care).Aim:To point out the significance of auscultation of the heart in the differentiation of heart murmurs and show clinical characteristics of accidental heart murmurs.Material and methods:Article presents review of literature which deals with the issue of accidental heart murmurs in the pediatric cardiology.Results:In the group of accidental murmurs we include classic vibratory parasternal-precordial Stills murmur, pulmonary ejection murmur, the systolic murmur of pulmonary flow in neonates, venous hum, carotid bruit, Potaine murmur, benign cephalic murmur and mammary souffle.Conclusion:Accidental heart murmurs are revealed by auscultation in over 50% of children and youth, with a peak occurrence between 3-6 years or 8-12 years of life. Reducing the frequency of murmurs in the later period can be related to poor conduction of the murmur, although the disappearance of murmur in principle is not expected. It is the most common reason of cardiac treatment of the child, and is a common cause of unreasonable concern of parents.

Brockenbrough-Braunwald-Morrow sign

A 56-year-old man presented with mild exertional dyspnea for one year. Cardiac auscultation noted a grade 3 ejection murmur at lower left sternal border which became louder and shorter (early systolic) after a …

PP-063 A Rare Cause of Left Ventricular Outflow Tract Obstruction: Elongated Mitral Chordae Tendineae

Fifty six years old asymptomatic, hypertensive male patient referred to our clinic for evaluation of cardiac murmur. Auscultation revealed a grade 3/6 systolic ejection murmur at right second intercostal space. 12 lead ECG showed sinus rhythm and voltage criteria for left ventricular (LV) hypertrophy (Cornell criteria). Transthoracic echocardiography revealed left ventricular concentric hypertrophy. Septal wall diastolic thickness was 14mm. Sixteen mmHg resting pressure gradient was measured at LVOT (Figure 1A). Gradient at LVOT augmented to 64mmHg with Valsalva maneuver (Figure 1B). But there was no SAM. Patient underwent transesophageal echocardiography (TEE) for detailed examination of pathology that cause LVOT obstruction. Transesophageal echocardiography clearly demonstrated systolic anterior prolapse of the elongated, floating-like chordae tendinea through the aortic valve (Figure 1C, Arrow). Color Doppler echocardiography showed narrowing of LVOT secondary to elongated chordae and resultant systolic turbulence (Figure 1D). Other cardiac structures were normal. We managed the patient medically and prescribed beta blocker.

Prediction of aortic stenosis-related events in patients with systolic ejection murmur using pocket-sized echocardiography

BackgroundWe have previously reported the usefulness of our newly developed visual aortic stenosis (AS) score in screening for AS using pocket-sized echocardiography. The objective of this study was to investigate whether the visual AS score and/or conventional aortic valve calcification score derived from pocket-sized echocardiography can be used to predict AS-related events. MethodsOne hundred and nine patients with systolic ejection murmur (SEM) or known AS (64 males, age 75±9 years) were enrolled and a visual AS score and an aortic valve calcification score were assessed using pocket-sized echocardiography. The primary endpoint was defined as AS-related events, including cardiac death and aortic valve replacement, during the follow-up period. ResultsIn a multivariate Cox proportional hazards analysis, AS-related events were independently predicted by an aortic valve calcification score ≥3 (HR, 3.5; 95% CI, 1.1–11; p=0.033) and a visual AS score ≥3 (HR, 15; 95% CI, 1.8–125; p=0.013). During 18±9 months of follow-up, the event-free survival rate was 98% in patients with both a visual AS score <3 and an aortic valve calcification score <3, 90% in patients with either a visual AS score ≥3 or an aortic valve calcification score ≥3 (p<0.0001), and 62% in patients with both a visual AS score ≥3 and an aortic valve calcification score ≥3 (p<0.0001). ConclusionsThe combination of visual AS score and aortic valve calcification score derived from pocket-sized echocardiography is useful for predicting AS-related events in patients with SEM.

Severe Hypoplasia of Posterior Mitral Valve Leaflet Presented with Atypical Chest Pain: A Case Report

Abstract Introduction: Absence of the posterior mitral leaflet is usually fatal for fetus in utero. Although hypoplasia of the posterior mitral leaflet is usually present in children with symptomatic mitral regurgitation, it is usually evident in a few cases of asymptomatic adults. We decided to introduce a rare case with hypoplasia of the posterior mitral valve leaflet associated with aortic stenosis. Case Presentation: A 24-year-old man was admittedwith a history of atypical chest pain. The patient had a normal psychophysical growth. The physical examination showed 4/6 mid- systolic ejection murmurs over the left sternal border. Chest roentgenogram was normal and the electrocardiogram showed sinus rhythm with mild LVH. Meanwhile, the echocardiography revealed severe elongated sail- like anterior leaflet and hypoplasia of the posterior mitral leaflet with moderate valvular aortic stenosis. MR grade was mild due to the complete coverage of anterior mitral leaflet. Moreover, LV function and pulmonary arterial pressure were reported normal. Conclusions: This abnormality was tolerated since adulthood and mitral regurgitation was gradually developed due to annulus dilation. Therefore, the posterior mitral leaflet did not have a significant impact on mitral valve performance.

Cardiac Examination: We Should Believe what We Hear and Feel

A 64 year old male with end stage renal disease on hemodialysis was evaluated for dyspnea in the emergency room. An urgent transthoracic echocardiogram done for the physical finding of systolic ejection murmur revealed severe aortic stenosis with valve area of 0.98 cm2. Cardiac catheterization revealed non-obstructive coronary artery disease and moderate aortic stenosis. Patient developed an access site hematoma resulting in prolonged hospital stay. In the meanwhile, hemodialysis resulted in relief of his dyspnea. The present case brings into perspective the importance of physical exam for efficient and ‘do not harm’ principle of medicine.

Case 2: Premature Infant With a Fontanelle Bruit

During routine weekend rounds, the nurse practitioner notes that an 11-day fontanelle of an infant born at 33 weeks’ gestation is pulsating. She listens with her stethoscope and auscultates a bruit. On examination, the infant is not tachypneic, and there is a soft systolic ejection murmur heard at the left sternal border radiating to the axilla without a gallop. Of note, there is also no hepatomegaly apparent on examination. The remainder of her examination findings are normal. ### History The infant is a twin female born at 331/7 weeks’ gestational age who is being managed in the neonatal intensive care unit (NICU) for prematurity and feeding difficulties. She was born to a 35-year-old, gravida 2, para 0010 woman whose pregnancy was complicated by preeclampsia, preterm premature rupture of membranes, and twin gestation. At birth, the infant weighed 2,285 g (77th percentile), her head circumference was 32 cm (86th percentile), and her Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Maternal prenatal test results were unremarkable, including a first trimester screen, ultrasonography, and glucose tolerance test. Prenatal medications included prenatal vitamins and one course of betamethasone. The mother denied smoking, alcohol, or drug use during the pregnancy. The infant is breathing comfortably in room air since birth. She is not anemic and is tolerating enteral feeds since they were initiated shortly after birth. She is not yet able to use a nipple for all her feeds, so she is being fed by gavage tube. Her history does not …

Quadricuspid pulmonary valve associated with atrial septal defects and pulmonary stenosis

A 1-month-old Hispanic female was referred to the cardiology service. During physical examination, a systolic ejection murmur at the pulmonic area was auscultated. The echocardiography evaluation of the pulmonary valve demonstrated a quadricuspid pulmonary valve (QPV) with slightly thickened leaflets, associated atrial septal defects and mild pulmonary stenosis. QPV is a rare congenital anomaly variant that can remain asymptomatic with few or non-hemodynamic alterations. Associations with structural or functional alterations have been reported. This is the first case of QPV that was diagnosed in a Hispanic newborn.

Osteomyelitis with a twist: Streptococcus pneumoniae causing sternoclavicular septic arthritis.

CASE PRESENTATION An 80-year-old woman of Caribbean descent with a history of type 2 diabetes mellitus, gout, osteoarthritis, gastrointestinal reflux and atrial fibrillation, presented with a 12 h history of left-sided shoulder, neck and back pain. Her temperature was 38.0°C and her white blood cell count was 15×109 cells/L. She experienced tenderness in the left sternoclavicular and sternomanubrial regions associated with warmth and erythema, but without an effusion. Her neck range of motion was restricted by pain on the left side, including neck deviation to the right, which was compatible with torticollis. She could not abduct her shoulder beyond 60 degrees. She had a III/VI systolic ejection murmur at the left upper sternal border, but no stigmata of infectious endocarditis. Her gastrointestinal, dermatological and respiratory examinations were within normal limits. On admission, she was empirically started on ceftriaxone for suspected shoulder joint septic arthritis. An unsuccessful attempt was made to aspirate the left shoulder joint. The pain progressed toward her anterior chest wall and within 72 h C-reactive protein levels had increased from 11 mg/L to 240 mg/L. Blood cultures were positive in three of three sets for penicillin-susceptible Streptococcus pneumoniae. Aspiration of the sternoclavicular joint (SCJ) was unsuccessful. Transesophageal echocardiography did not reveal evidence of endocarditis. The chest radiograph did not reveal evidence of pneumonia. Despite prolonged antibiotic therapy, the patient never experienced full recovery of function, primarily with respect to arm adduction, which was limited by pain at the SCJ. Repeat computed tomography (CT) scan after therapy revealed arthritic changes related to her treated infection. Avoidance of pain led to the patient’s torticollis, which was the most distressing clinical feature for her. This persisted for months despite regular physiotherapy sessions.

Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions.

Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection.

ECG Challenge: December 9, 2014

HomeCirculationVol. 130, No. 24ECG Challenge: December 9, 2014 Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBECG Challenge: December 9, 2014 Originally published9 Dec 2014https://doi.org/10.1161/CIRCULATIONAHA.114.014063Circulation. 2014;130:2209A 67-year-old woman with a history of hypertension treated with an angiotensin-converting enzyme inhibitor and β-blocker presents to her primary care physician for a routine physical examination. She has no complaints. Her blood pressure is normal, and the rest of her physical examination is unremarkable except for a grade II/IV harsh early peaking systolic ejection murmur at the second intercostal space. It radiates to her neck. Her carotid pulses are normal. Her pulse is noted to be irregular, and an ECG is obtained.Download figureDownload PowerPointWhat is the diagnosis?To submit your diagnosis, go to http://circ.ahajournals.org/letters/submit/circulationaha;130/24/2209. The diagnosis will follow in the December 23/30 issue.Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.FootnotesCorrespondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetails December 1, 2014Vol 130, Issue 24 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.014063 Originally publishedDecember 9, 2014 PDF download Advertisement

Teaching auscultation visually with low cost system, is it feasible?

Cardiac auscultation can generate important information in the diagnosis of diseases. The sounds that the cardiac system provides are understood in the frequency range of human hearing, but in a region of low sensitivity. This project aims to build a low cost didactic software/hardware set for teaching cardiac auscultation technique in Brazilian universities. The frequencies of interest to describe the human cardiac cycle were found in the range of 20 Hz to 1 kHz which includes low frequencies where available low-cost transducers usually have large errors. To create the system, an optimization of the geometry of the chestpiece is being programmed with finite element simulations; meanwhile, digital filters for specific frequencies of interest and an interface based on MATLAB are being developed. There were needed filters for the gallops (20 to 70 Hz), heart beats (20 to 100 Hz), ejection murmurs (100 to 500 Hz), mitral stenosis (30 to 80 Hz), and regurgitations (200 to 900 Hz). The FEM simulation of a chestpiece demonstrates high signaling levels on the desired frequency range, which can be used with the filters to obtain specific information. Furthermore, the ideal signal recording equipments will be defined, implemented, and tested.

Physical Diagnosis

Ad Libitum15 July 2014Physical DiagnosisJack Coulehan, MD, MPHJack Coulehan, MD, MPHFrom Setauket, New York.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-0149 Audio Reading - “Physical Diagnosis” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "Physical Diagnosis," by J. Coulehan. Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail InspectionWe snap on both lights and shake himuntil he wakes. To get a good look,we make him flip to the prone positionand untie his gown. Amazing! Well-worththe extra trip. His lesions blanketthe upper back like thousands of fish eggsin a salmon-colored cloud. Among themare jagged claws of excoriations—he can't stop scratching. Even drugsdon't calm him down. His only comfortis sleep. Sleep and studio wrestling.to ignore us grimaces when ... Author, Article, and Disclosure InformationAffiliations: From Setauket, New York.Current Author Address: Jack Coulehan, MD, MPH, e-mail, John.[email protected]edu. PreviousarticleNextarticle Advertisement Audio Reading - “Physical Diagnosis” Audio. Michael A. LaCombe, MD, Annals Associate Editor, reads "Physical Diagnosis," by J. Coulehan. Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics Cited byToward a Renascence of Physical Diagnosis in the Intensive Care Unit 15 July 2014Volume 161, Issue 2Page: 160KeywordsBatsDrugsHearingHeartInflammationLesionsScarsSleepSpleenSystolic ejection murmur ePublished: 15 July 2014 Issue Published: 15 July 2014 Copyright & PermissionsCopyright © 2014 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Silent Embolization of an Atrial Septal Defect Occluder Into the Right Ventricle Detected 20 Months Post-Implantation

A 64-year-old woman, who had undergone transcatheter closure of a secundum-type atrial septal defect (ASD) with a 38-mm Amplatzer septal occluder (ASO) 20 months earlier, was admitted with palpitations for 1 day. She had not received routine follow-up after the procedure. Cardiac examination revealed a grade III/VI systolic ejection murmur at the left upper sternal border. Chest x-ray revealed that the ASO device was located in the right ventricular area (Fig. 1A). Immediate transthoracic echocardiography confirmed that the ASO device had become dislodged and embolized into the right ventricle. The embolized device was oriented in the longitudinal plane, parallel to the direction of blood flow across the tricuspid valve (Fig. 1B). Although the patient remained hemodynamically stable, she was referred for urgent surgical retrieval of the device and closure of the defect. In surgery, the embolized occluder was identified in the right ventricular inflow tract and appeared to be firmly adhering to the tricuspid valve apparatus (Fig. 1C). The inferoposterior rim of the ASD was also found to be inadequate. The endothelialization status of the retrieved device revealed that embolization must have occurred months earlier (Fig. 1D). The ASD was closed with a bovine pericardial patch through the right atriotomy, and the tricuspid valve was repaired with a 32-mm CosgroveEdwards annuloplasty band (Edwards Lifesciences, Irvine,

Giant Aortic Root Aneurysm Presenting as Acute Type A Aortic Dissection

A 49-year-old woman with four months of increasing episodic palpitations, chest pain, and shortness of breath presented to an outside clinic where a new 4/6 systolic ejection murmur was identified. A transthoracic echocardiogram revealed a large aortic root aneurysm. The patient underwent emergent repair of the dissected root aneurysm with a modified Bentall procedure utilizing a #19 St Jude Valsalva mechanical valve conduit. Postoperatively, she required a permanent pacemaker placement. Her echo showed ejection fraction improvement from a preoperative 25% to a postoperative 35%. She was discharged home on postoperative day 7.