Severe aortic regurgitation with ascending aortic dilatation in a young adult with bicuspid aortic valve

Yasika1*, Sripreethi2, Jayamenon3

1Staff Nurse, Kauvery Hospital, Heartcity, Trichy, Tamil Nadu

2Nurse Educator, Kauvery Hospital, Heartcity, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Heartcity, Trichy, Tamil Nadu

*Correspondence

Abstract

Bicuspid aortic valve (BAV) is a common congenital cardiac abnormality that may lead to serious complications such as aortic regurgitation, aortic root dilatation, and heart failure. We report the case of a 27-year-old male who presented with complaints of palpitations, sweating, cough, and progressive shortness of breath. Clinical examinations and investigations revealed severe aortic regurgitation associated with bicuspid aortic valve and significant ascending aortic dilatation. Echocardiography demonstrated left ventricular hypertrophy, severe aortic regurgitation, aortic root dilatation, and reduced left ventricular ejection fraction of approximately 35%. The patient was initially managed with medical stabilization for acute decompensated heart failure and later evaluated for surgical intervention, including aortic valve replacement with possible Bentall procedure. This case highlights the importance of early diagnosis, echocardiographic evaluation, and timely surgical management in young patients with congenital valvular heart disease to prevent progression to irreversible cardiac dysfunction and life-threatening complications.

Keywords: Bicuspid aortic valve; Aortic regurgitation; Aortic root dilatation; Acute heart failure; Bentall procedure; Echocardiography.

Introduction

Bicuspid aortic valve is one of the most common congenital cardiac abnormalities. It may remain asymptomatic for years but can later lead to complications such as aortic stenosis, aortic regurgitation, infective endocarditis, and aortic root dilatation. Severe aortic regurgitation can cause left ventricular dilatation and heart failure if untreated. Early recognition and prompt surgical management are essential to improve patient outcomes.

Case Presentation

A 27-year-old male was admitted with complaints of:

  • Sweating
  • Palpitations
  • Cough for 2 days
  • Shortness of breath on exertion

The patient had a recent history of upper respiratory symptoms and worsening breathlessness. No relevant personal or family history .Initially, he was treated elsewhere and later referred to for cardiology evaluation due to abnormal ECG and persistent symptoms.

On admission, he was conscious and oriented but tachycardic and hypertensive. Examination suggested features of acute heart failure.

Clinical Findings

Vital Signs

BP170/60 mmHg
HR30–136 bpm
RR20/min
SpO₂97–98%
TemperatureAfebrile

Cardiovascular Examination

  • Tachycardia present
  • Murmur suggestion of aortic regurgitation
  • Signs of left ventricular enlargement

Diagnosis

ECG Findings

  • Left ventricular hypertrophy (LVH)
  • Sinus tachycardia

Echocardiography Findings

  • Bicuspid aortic valve
  • Severe aortic regurgitation
  • Aortic root dilatation
  • Ascending aorta dilated (~65 mm)
  • Left ventricular dysfunction
  • Ejection fraction approximately 35%

Lab Investigations

Final Diagnosis

Severe Aortic Regurgitation is secondary to Bicuspid Aortic Valve with Aortic Root Dilatation presenting as Acute Decompensated Heart Failure.

Management

Medical Management

  • Oxygen therapy to maintain adequate saturation
  • Diuretics for reducing pulmonary congestion and fluid overload
  • Antihypertensive medications for blood pressure control
  • Vasodilator therapy to reduce afterload in severe aortic regurgitation
  • Monitoring of urine output and fluid balance
  • Electrolyte correction and renal function monitoring
  • Monitoring
  • Continuous ECG monitoring
  • Vital signs monitoring
  • Intake and output charting
  • Serial cardiac assessment

Pre-Operative Management

The patient was diagnosed with severe aortic regurgitation with bicuspid aortic valve and aortic root dilatation presenting with acute decompensated heart failure. Pre-operative management focused on stabilization of hemodynamic status and preparation for surgery.

  • Stabilize heart failure symptoms
  • Control blood pressure and tachycardia
  • Improve oxygenation
  • Preventing complications
  • Prepare patient for definitive surgical intervention

Surgical Preparation

  • Cardiothoracic surgery consultation obtained
  • Informed consent explained regarding valve replacement/Bentall procedure.
  • Nil per oral (NPO) status maintained before surgery
  • Pre-anesthetic evaluation completed
  • Infection prevention measures followed

Post-Operative Management

Post-operative care mainly focused on hemodynamic stabilization, prevention of complications, pain management, and recovery after cardiac surgery.

  • Immediate Post-Operative Care
  • ICU monitoring
  • Mechanical ventilation support if required
  • Hemodynamic monitoring
  • Arterial blood pressure monitoring
  • Central venous pressure monitoring
  • Continuous cardiac rhythm monitoring
  • Medications
  • Analgesics for pain management
  • Antibiotics to prevent infection
  • Anticoagulants if prosthetic valve inserted
  • Diuretics as needed
  • Inotropic support if low cardiac output present

Nursing Management

  • Monitoring of vital signs
  • Chest drains monitoring
  • Strict intake and output charting
  • Wound care and sterile dressing
  • Early detection of bleeding or arrhythmias
  • Monitoring for signs of infection
  • Respiratory Care
  • Oxygen supplementation
  • Incentive spirometry
  • Chest physiotherapy
  • Early extubating if stable
  • Mobilization and Rehabilitation
  • Early ambulation
  • Gradual increase in activity
  • Cardiac rehabilitation advice
  • Dietary counseling and salt restriction
  • Monitoring for Complications
  • Arrhythmias
  • Heart failure
  • Prosthetic valve complications
  • Bleeding
  • Thromboembolism
  • Infection

Discharge Advice

  • Regular follow-up with cardiologist
  • Medication compliance
  • Lifestyle modification
  • Monitoring INR if mechanical valve is used
  • Endocarditis prophylaxis education
  • Avoid heavy exertion initially

Discussion

Bicuspid aortic valve is a congenital abnormality affecting approximately 1–2% of the population. Patients may remain asymptomatic until complications develop. Severe aortic regurgitation causes volume overload of the left ventricle, leading to ventricular dilatation and systolic dysfunction. Aortic root dilatation is a recognized association with bicuspid aortic valve disease and significantly increases the risk of aortic aneurysm and dissection. In this patient, severe aortic regurgitation and marked ascending aortic dilatation resulted in acute heart failure symptoms at a young age. Echocardiography plays a crucial role in diagnosis and surgical planning. Definitive treatment generally involves valve replacement with repair or replacement of the dilated aortic root when indicated.

Conclusion

This case demonstrates an unusual presentation of severe bicuspid aortic valve disease in a young adult presenting with acute heart failure. Early identification through echocardiography and timely surgical intervention are important to prevent life-threatening complications and improve long-term prognosis.

References

  • American Heart Association. (2020). 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation, 143(5), 72–227.
  • Otto, C. M., & Bonow, R. O. (2021). Valvular heart disease: A companion to Braunwald’s heart disease (5th ed.). Elsevier.
  • Nishimura, R. A., Otto, C. M., & Bonow, R. O… (2017). AHA/ACC focused update of the guideline for the management of patients with valvular heart disease. Journal of the American College of Cardiology, 70(2), 252–289.
  • Braverman, A. C… (2011). The bicuspid aortic valve and associated aortic disease. Cardiology Clinics, 28(2), 239–254.
  • Hiratzka, L. F., et al. (2010). Guidelines for the diagnosis and management of thoracic aortic disease. Circulation, 121(13), 266–369.

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