When the mass deceives: A case of chronic type a aortic dissection mimicking infective endocarditis in recurrent heart failure

Abstract Background Aortic dissection (AD) typically presents with classic tearing chest pain; however, atypical presentations can lead to significant diagnostic delays, especially when manifesting as heart failure. In chronic cases, the intimal flap may undergo progressive fibrosis and calcification, resulting in an echogenic appearance that can potentially mimic infective endocarditis (IE) during initial echocardiographic assessments. Case Illustration A 73-year-old female with untreated hypertension presented with recurrent acute decompensated heart failure (ADHF) over a six-month period, notably absent of chest pain. Clinical examination revealed wide pulse pressure (122/60 mmHg). Transthoracic echocardiography (TTE) identified aortic root dilation, severe aortic regurgitation, and a mobile, vegetation-like mass at the aortic valve, initially raising suspicion for IE. However, the patient remained afebrile with normal inflammatory markers. Further evaluation using transesophageal echocardiography (TEE) and computed tomography angiography (CTA) definitively diagnosed a chronic Type A aortic dissection; the vegetation was confirmed to be a calcified intimal flap. CTA also revealed significant multi-vessel coronary artery disease. The patient successfully underwent a Bentall procedure and concomitant coronary artery bypass grafting. Postoperative evaluations confirmed stable prosthetic valve function, and subsequent monthly follow-ups showed no recurrence of heart failure symptoms, demonstrating a successful clinical outcome. Conclusion Chronic Type A aortic dissection can masquerade as IE and presented as recurrent ADHF. Clinicians must maintain a high suspicion for aortic pathology in patients with recurrent ADHF and valvular abnormalities, even without classic symptoms. Multimodal imaging is essential to differentiate chronic intimal flaps from infectious masses.Figure 1.(A) Vegetation-like mass on parasternal short axis view at aortic valve level on systole and (B) diastole (yellow arrows); (C) Transthoracal echocardiography showing aortic root dilation; (D) Transesophageal echocardiography showing aortic dissection with intimal flap; (E) Computed Tomography Angiography showing type A aortic dissection