A Conservatively Managed Giant Ascending Aortic Aneurysm Presenting With New Atrial Fibrillation and Heart Failure

Ascending aortic aneurysms bigger than 9 cm are not common these days.Most are found and fixed while they are still much smaller.We report an 88-year-old woman who came into hospital with palpitations, worsening breathlessness on exertion, and swollen ankles.She had a history of high blood pressure, stage 3 kidney disease, and high cholesterol.On examination, her pulse was irregular, she had crackles at the bottom of both lungs, and swelling up to her knees.Her ECG showed atrial fibrillation with a fast heart rate, and her B-type natriuretic peptide (BNP) blood test was very high at 4544 ng/L.She was treated for heart failure caused by the new atrial fibrillation and started on medicine to slow her heart rate and thin her blood.An echo scan, done just to check how well her heart was pumping, picked up something unexpected: the main part of her aorta near the heart was very dilated, there was leaking through the aortic valve, and there was fluid around the heart.A CT scan confirmed a 9.3 cm aneurysm of the ascending aorta, starting at the root, with no tear or bleeding.The heart surgeons felt she was too old and frail, with too many other health problems, to have surgery to fix it.She was treated for decompensated heart failure occurring in the setting of new-onset atrial fibrillation with a rapid ventricular response and was started on rate-control therapy and anticoagulation.We talked to her about whether to keep her on blood thinners even though the aneurysm could not be repaired.She chose to stay on her blood thinner after the risks were explained to her.She went home after five days and was doing better when seen again two months later, and the aneurysm had not grown.This case shows how much a routine echo can find, and how hard the decision about blood thinners can be when there is an aneurysm that cannot be operated on.