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A 61-year-old man with a history of hypertension presented to the emergency department with a 1-day history of fever, dyspnea, and generalized weakness. His vital signs were temperature, 38.4°C (101.1°F); blood pressure, 94/40 mm Hg; heart rate, 116/min; and respiratory rate, 26/min. He was diaphoretic and had poor dentition. A soft S1 was present on cardiac examination, and crackles were auscultated in basilar lung fields bilaterally. Three sets of blood cultures from different sites were obtained. Cardiology, cardiac surgery, and infectious disease physicians were consulted. A bedside transthoracic echocardiogram was performed, the patient was transferred to the intensive care unit, and a transesophageal echocardiogram was obtained (Figure 1).
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Severe acute aortic regurgitation secondary to infective endocarditis
B. Perform emergency surgery for aortic valve repair
The key to the correct diagnosis is the presence of fever and hemodynamic instability with physical examination findings consistent with pulmonary edema and aortic regurgitation. Imaging demonstrated acute regurgitation, consistent with acute aortic valve insufficiency. Emergency intervention is indicated because of his symptoms of heart failure.
Acute aortic regurgitation causes a sudden reflux of blood from the aorta into the left ventricle during diastole. Decreased cardiac output results in compensatory tachycardia and increased myocardial oxygen demand. The incompetent aortic valve reduces coronary arterial flow, impairing myocardial perfusion. Increased left atrial pressure causes flash pulmonary edema, leading to cardiopulmonary failure.1 Symptoms of acute aortic regurgitation include diaphoresis, fatigue, and dyspnea. Examination may reveal a widened pulse pressure from decreased diastolic pressure or a soft S1 murmur caused by increased left ventricular diastolic pressure and early mitral valve closure. A faint systolic murmur may be present if aortic regurgitation is severe. Bilateral crackles from pulmonary edema may be auscultated.1
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Corresponding Author: Nicholas Oh, MD, University of California, Los Angeles, 10833 Le Conte Ave, 72-227 CHS, Los Angeles, CA 90095 (firstname.lastname@example.org).
Published Online: May 20, 2019. doi:10.1001/jama.2019.6546
Conflict of Interest Disclosures: None reported.
Additional Information: We thank the patient’s sister for providing permission to share the patient’s information.
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