Dyspnoea during exertion ...

A 25-year-old man was referred to the tertiary centre for dyspnoea during exertion with a presence of heart murmur sound. Due to congenital aortic valve disease (AV), the patient’s father underwent aortic valve replacement (AVR) for congenital aortic valve disease. A diastolic sound was heard in the aortic lesion on physical examination. The lung sounds were clear and there was no peripheral oedema. Chest x-ray showed an increased cardiothoracic ration and marking of pulmonary blood vessels compatible with interstitial pulmonary oedema. The ESR was normal on laboratory blood tests and negative for CRP, procalcitonin, and blood cultures. Transthoracic echocardiography showed a slight enlargement of the left ventricle (LV), a slight contractile dysfunction with an LV ejection fraction of 50%, an increase in LV filling pressure. The mitral tricuspid and pulmonary valves were normal, and there was no significant regurgitation or stenosis. However, early closure of the mitral valve was noted. The aortic valve is thickened, calcified and bicuspid, with flapping wings on both leaflets, which mimics the composition of the heart with a five-cavity image at the apex, resulting in aortic regurgitation.