Introduction

A 77-year-old man presents for a preoperative evaluation before a hernia repair. He has a history of a previous myocardial infarction (6 years ago), and 2 years ago he underwent cardiac catheterization and a percutaneous coronary intervention because of drug-refractory angina pectoris. Since that time, he has been free of cardiac symptoms, but the surgeon requested a preoperative cardiac evaluation because of his history. Physical examination demonstrates normal heart sounds, but there is a grade 2/6 harsh midsystolic murmur heard at the base with faint radiation to the carotids. It is felt to represent aortic sclerosis. Paradoxical splitting of S2 is also appreciated.

What is the diagnosis?

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