Congenital aortic bicuspid valve can evolve rapidly and at an early age to a severe aortic disease with significant stenosis and regurgitation. Therefore, cardiovascular surgery with mechanical aortic prosthesis implant is the only therapeutic solution. Despite a successful surgical procedure, complications can be numerous, especially post-operatively, as conduction disorders and arrhythmias. Also, given the recent guidelines recommendations to maintain the INR values above 2,5, chronic oral anticoagulation is critical in the long-term prevention of cardioembolic events. Thus, we are presenting the case of a patient diagnosed with a severe aortic disease secondary to a bicuspid aortic valve, who underwent a Bentall surgical procedure, later suffering a wide spectrum of complications, both immediate and late, especially due to long-term subtherapeutic INR values. The particularities of the case reside both in the multitude of complications that occurred in a particular chronological order and in the interfering mechanisms with the anticoagulant therapy.

Thrombophilia is a blood coagulation disorder, in which blood has an increased tendency to clot, with both arterial and venous localization, being responsible for multiple manifestations: secondary arterial hypertension, stroke, acute pancreatitis or intracardiac masses. We are presenting the case of a 21-year-old male patient, hypertensive, known with thrombophilia, who was sent for the echocardiographic evaluation of an intracardiac mass attached to the posterior leaflet of the mitral valve. The echocardiography and transesophageal echocardiogram showed a hyperechogenic, homogeneous intracardiac mass, attached to the posterior leaflet of the mitral valve, the clinical context and the echocardiographic appearance being suggestive for a thrombus. Given the context of thrombophilia and the hypertension’s characteristics, we considered a secondary form of hypertension, the incriminated mechanism being represented by microthrombosis in the renal arterial circulation. There were two complications in the evolution of the patient: stroke and the recurrent acute pancreatitis, both being explained in the context of thrombophilia. The discharge echocardiography showed a favorable evolution, with a complete resolution of the thrombus under the anticoagulant treatment.

Takotsubo syndrome occurs in 1-2% of patients admitted in the emergency department with suspicion of ST-segment elevation myocardial infarction (STEMI), over 90% being postmenopause women. Psycho-emotional or physical stress is the main trigger that causes the release of catecholamines, with an important role in the pathophysiology of Takotsubo cardiomyopathy. In most cases, supportive and symptomatic treatment is sufficient, with a dynamic follow-up of the left ventricular (LV) function. Usually, a complete recovery occurs in 3-4 weeks. We are presenting the case of a 67-year-old patient with a severe angina attack which occuredafter a major psycho-emotional stress, with an electrocardiographic appearance of an anterior STEMI and echocardiographic apical ballooning, both compatible with Takotsubo syndrome. Coronary angiography showed a muscle bridge with a systolic compression of 75% on the anterior descending artery (ADA). The evolution was marked by the occurrence of cardiogenic shock remitted under treatment, with complete recovery of LV systolic function. The particularity of the case resides in an acute coronary syndrome (ACS) after a psycho-emotional stress associated with a muscular bridge, as well as the appearance of the cardiogenic shock.