The patient presented again in January 1987 with dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination at that time revealed blood pressure with a widened pulse pressure of 120/40 mm Hg. Rapid carotid upstrokes were present. A grade 3 aortic insufficiency murmur was heard at the lower right sterna] border. A grade 3/6 systolic murmur was present in the aortic area. An Austin Flint murmur was present at the apex.
Electrocardiogram showed left ventricular hypertrophy with ST-T changes. Chest roentgenogram (Fig 3) showed the interim development of marked cardiomegaly with extreme dilatation of the aortic root. Echocardiogram showed severe left ventricular dilatation with an end-systolic dimension of 8.2 cm with diffuse left ventricular hypokinesis. The aortic root dimension was 6.5 cm. Diastolic flutter of the mitral valve was present compatible with aortic regurgitation. Pulse-wave Doppler documented severe aortic regurgitation. The patient was discharged from the hospital with medical therapy for congestive heart failure.

Figure 3. Chest roentgenogram in 1987 showing development of marked cardiomegaly with extreme dilatation of the aortic root.