A 40-year-old man with bicuspid aortic valve and huge LV

A 40-year-old man with bicuspid aortic valve and huge LV CLINICAL INTRODUCTION A 40-year-old man presented to our institute with progressive exertional dyspnoea for 1 year. Bicuspid aortic valve (BAV) with mild-to-moderate aortic regurgitation (AR) was diagnosed in his childhood by echocardiography, but he declined follow-up after-wards. Physical examination revealed a grade 3/6 'to-and-fro' murmur at the third left intercostal space. Chest radiograph showed an extremely enlarged cardiac silhouette (figure 1A), and ECG displayed complete left bundle branch block with frequent premature ventricular contractions. Transthoracic echo-cardiography demonstrated an extremely enlarged LV with end diastolic volume of 472 mL and EF of 20% (see figure 1B, C and online supplementary video 1). QUESTION Based on these imaging and clinical findings, what is the most likely cause of the patient's AR? A. Aortic dissection B. Aortico-left ventricular tunnel C. Avulsion of anterior cusp from aortic annulus D. Ruptured paravalvular abscess E. Ruptured sinus of Valsalva aneurysm For the answer see page 1080 Figure 1 Chest radiograph (A), short axis (B) and long axis (C) transthoracic imaging of the aortic valve.