Ascending aortic obstruction produced by dissected intimal flap.

The patient, a 67-year-old woman, mildly hypertensive for 13 years, experienced an episode of severe interscapular back pain associated with syncope two years previously. She had been admitted to hospital for six weeks and told she had had a "heart attack". Two weeks before admission she had another episode of severe interscapular back pain, with radiation down both arms, again associated with syncope of unknown duration. She did not seek medical attention for three days after this episode during which she became increasingly dyspnoeic on exertion. When seen by her doctor prominent systolic and diastolic murmurs were heard, apparently for the first time, and she was referred to hospital. On physical examination there were no stigmata of Marfan's syndrome. The carotid arteries showed a brisk upstroke and there were bruits on both sides. A prominent sustained apical impulse was noted in the sixth intercostal space in the anterior axillary line, with an additional ectopic impulse along the left sternal border in the second intercostal space. Pulsation of the left sternoclavicular joint was present. A systolic ejection murmur, grade 3/6, was present, loudest in the third left intercostal space and radiating to the carotids. A