Aneurysm of the ascending aorta with severe valvular insufficiency and atypical onset presenting as epigastric pain. Case report

Abstract

Background. Ascending aortic aneurysm represents a severe cardiovascular pathology with a high risk of dissection or rupture, and nonspecific clinical manifestations, such as epigastric pain, may delay accurate diagnosis and initiation of treatment, significantly worsening the patient’s prognosis. Objective(s). Presentation of a case of ascending aortic aneurysm with atypical onset, complicated by acute dissection undetected on imaging and severe valvular insufficiency, successfully treated surgically. Materials and methods. A 50-year-old hypertensive man was admitted to a regional hospital with severe abdominal pain, chills, nausea, and vomiting. After 9 days he was transferred to a tertiary care center due to progressive heart failure and poor response to treatment. He was evaluated by laboratory tests, echocardiography, thoracic CT angiography, coronary angiography. Results. Echocardiography revealed an aneurysm of the ascending aorta and Valsalva sinus (61 mm), grade IV aortic regurgitation, grade III mitral regurgitation, grade II tricuspid regurgitation, with preserved ejection fraction. Angio-CT confirmed the aneurysm without dissection. Coronary angiography showed no ischemic lesions. Intraoperatively, a Stanford type A, DeBakey type II dissection was found in the proximal ascending aorta with involvement of the aortic valve, which was not detected by imaging. A Bentall procedure was performed, including valve replacement, reimplantation of the coronary arteries, and repair of the aortic dissection. Conclusion(s). Atypical onset with epigastric pain and heart failure may delay the diagnosis of aortic aneurysms. Imaging may be inconclusive in the early detection of dissection, and intraoperative assessment remains essential for establishing the diagnosis and appropriate therapeutic approach.