Three main symptoms in patients with severe symptomatic aortic stenosis are presented below. Which symptom heralds the worst prognosis with median survival of two years?

Please identify the correct diagnosis based on images below a) chest x-ray (left) and b) computed tomography image (right).

An

82-years-old retired solicitor presents to the ED with chest pain radiating to

his jaw. He has hypertension treated with ramipril 5 mg bid (ACE inhibitor) but

is otherwise normally fit and well. His admission ECG shows sinus rhythm with

ventricular rate of 57 bpm, LV hypertension, and widespread ST segment

depression. His peak troponin is 110 ng/l (normal <30 ng/l). He is started

on treatment for an acute coronary syndrome and listed for an inpatient

angiogram. You are asked to perform bedside echocardiogram as a systolic murmur

is heard on the post-take ward round. His aortic valve is heavy calcified,

maximal trans-aortic jet velocity is 4.3 m/s, peak trans-aortic gradient is 75

mmHg, mean trans-aortic gradient is 46 mmHg (Figure below). 

Please name the type of aortic dissection shown below:

Which

patient(s) is considered to have severe aortic stenosis?

An

82-years-old retired solicitor presents to the ED with chest pain radiating to

his jaw. He has hypertension treated with ramipril 5 mg bid (ACE inhibitor) but

is otherwise normally fit and well. His admission ECG shows sinus rhythm with

ventricular rate of 57 bpm, LV hypertension, and widespread ST segment

depression. His peak troponin is 110 ng/l (normal <30 ng/l). He is started

on treatment for an acute coronary syndrome and listed for an inpatient

angiogram. You are asked to perform bedside echocardiogram as a systolic murmur

is heard on the post-take ward round. His aortic valve is heavy calcified,

maximal trans-aortic jet velocity is 4.3 m/s, peak trans-aortic gradient is 75

mmHg, mean trans-aortic gradient is 46 mmHg (Figure below). 

An

82-years-old retired solicitor presents to the ED with chest pain radiating to

his jaw. He has hypertension treated with ramipril 5 mg bid (ACE inhibitor) but

is otherwise normally fit and well. His admission ECG shows sinus rhythm with

ventricular rate of 57 bpm, LV hypertension, and widespread ST segment

depression. His peak troponin is 110 ng/l (normal <30 ng/l). He is started

on treatment for an acute coronary syndrome and listed for an inpatient

angiogram. You are asked to perform bedside echocardiogram as a systolic murmur

is heard on the post-take ward round. His aortic valve is heavy calcified,

maximal trans-aortic jet velocity is 4.3 m/s, peak trans-aortic gradient is 75

mmHg, mean trans-aortic gradient is 46 mmHg (Figure below). 

You manage a 28 years old female patient with Marfan syndrome. Her blood

pressure is normal (below 130/80 mmHg), she is in sinus rhythm with HR around

65 bpm. On TTE her ascending aorta is dilated up to 46 mm with only mild aortic

regurgitation. Patient has desire for pregnancy. What are your suggestions for

further management of this young lady?

Clinical features of severe Aortic Stenosis include: