- A 32-YEAR-OLD, 87-kg, 173-cm man with a past medical history of a congenital bicuspid aortic valve was admitted to the authors' hospital for evaluation of dyspnea on exertion. The patient had been a frequent participant in strenuous athletic activities including full-court basketball. He reported that his stamina during these activities had declined substantially in recent months. The patient also described unusual episodes of fatigue while performing his job as a biomedical engineer. He denied a history of angina pectoris, syncope, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema.
- A DISORIENTED 58-YEAR-OLD, 96-kg, 177-cm man was transported by helicopter to the authors' institution for treatment of an acute type-A aortic dissection. A computed tomography (CT) scan with angiographic contrast showed aneurysmal dilatation of the ascending thoracic aorta and an acute type-A aortic dissection originating proximal to the sinotubular junction that extended to the left iliac artery. The right iliac artery was poorly visualized. Right femoral and dorsalis pedis pulses were absent, but blood flow to the right leg was verified with Doppler ultrasound.
- A 63-YEAR-OLD, 105-kg, 177-cm man was admitted to the authors' institution for the evaluation of progressive exertional pain located primarily in his left chest without radiation to the jaw or left arm. The pain was consistently relieved by rest or oral nitroglycerin. The patient denied dyspnea, orthopnea, palpitations, and peripheral edema. His past medical history was notable for hypertension, hypercholesterolemia, tobacco abuse, and a previous lateral wall myocardial infarction that occurred 7 years before the current admission.
- A 77-YEAR-OLD, 121-kg, 172-cm man presented to the authors' institution for the evaluation of progressive dyspnea on exertion, paroxysmal nocturnal dyspnea, and severe fatigue. The patient had a past medical history of coronary artery disease and a previous myocardial infarction that had been medically managed 19 years before admission. The past medical history was remarkable for cardioversion-resistant chronic atrial flutter for which the patient was treated with warfarin. The patient also described a history of hypertension, type II diabetes mellitus, and hypercholesterolemia.
- A 73-YEAR-OLD man returned to the authors' institution for evaluation of a 1-week history of progressively increasing shortness of breath, paroxysmal nocturnal dyspnea, fatigue, and chills with rigors. The patient had undergone an aortic valve replacement with a 23-mm porcine bioprosthesis and 2-vessel coronary artery bypass graft surgery for the treatment of severe aortic stenosis and coronary artery disease, respectively, 1 month before he was readmitted. Except for a brief episode of atrial flutter requiring pharmacologic intervention, his initial postoperative course had been unremarkable until his symptoms began.
- A 66-YEAR-OLD, 80-kg, 172-cm man presented to the authors' institution for evaluation of a syncopal episode. The patient reported a past medical history of a bicuspid aortic valve disease complicated by moderate-to-severe aortic insufficiency, an ascending aortic aneurysm (maximum diameter of 4.8 cm), and chronic renal insufficiency related to essential hypertension and a previous left nephrectomy. The physical examination was notable for a soft diastolic murmur appreciated best over the right sternal border.
- A 72 YEAR-OLD, 70-kg, 170-cm man presented to the authors' institution for evaluation of progressively worsening chest pain and tightness that were relieved by rest. These chest symptoms were located throughout his anterior chest but did not radiate to his jaw, left shoulder, or back. His symptoms were accompanied by pronounced dyspnea on exertion, easy fatigability, and orthostatic near syncope. Medical treatment with calcium channel and β1-adrenoceptor antagonists (diltiazem and metoprolol, respectively) failed to substantially improve his symptoms.
- AN 81-YEAR-OLD, 71-kg, 174-cm man with a past medical history of chronic atrial fibrillation, hypertension, hyperlipidemia, and mitral valve prolapse caused by childhood rheumatic fever presented to the authors' institution for the evaluation of worsening dyspnea. The patient reported generalized malaise, was easily fatigued and very short of breath with minimal exertion, had a nonproductive dry cough after lying flat, and described a progressive history of orthopnea and paroxysmal nocturnal dyspnea that had become so severe that he slept poorly while sitting upright in a chair.