An Inverted Location of the Bicuspid Valve Disease

A 70-year-old woman was referred to cardiac evaluation because of the detection of dilation of the main pulmonary artery by chest computed tomography performed before the removal of a thoracic lipoma. The computed tomography scan with contrast also excluded arterial thromboembolism of the main and distal pulmonary branches.The patient had a previous diagnosis of mild pulmonary stenosis with a right ventricle-pulmonary artery peak systolic pressure gradient of 24 mm Hg by right catheterization in 1978. Since then, the patient has been asymptomatic, and she has been conducting normal daily-life activities without undergoing further cardiovascular controls. In 2001, a previous computed tomography scan had already shown mild dilatation of the main pulmonary artery for which no investigation was later performed.On the first evaluation, the patient was asymptomatic, her heart rate was 83 bpm, and her blood pressure was 130/70 mm Hg. Cardiac examination revealed a regular rhythm, with a 3/6 systolic murmur at the upper right and left sternal border. Lung fields were normal; neither jugular venous distention nor hepatomegaly and peripheral edema were detected. The ECG showed sinus rhythm and normal atriventricular and intraventricular conduction, with slight ST-segment abnormalities in inferior leads.Transthoracic echocardiography (Figure 1 and Movie I in the online-only Data Supplement) confirmed the presence of significant dilation of the main pulmonary …