Case Reports in Medicine factor for these late dissections [2–11]. In patients with thinned and fragile aortic wall even in the absence of mark- edly dilated aortic root, prophylactic replacement or wrap- ping of the ascending aorta should be considered at the time of AVR procedure. In addition, elective reoperation has been also recommended for patients with history of previous AVR, and ascending aorta diameter greater than 50 mm [6, 7]. In the present case, the diameter of the ascending aor- ta has increased to 11 mm 6 years after AVR and giant pseu- doaneurysm has been diagnosed after symptoms due to dis- section. Patient has had back pain, although the pain due to ascending dissection is expected to be in more anterior location. The aortic size and previous AVR have been sup- posed as predictors for back pain and late ascending aor- tic dissection in our case. Patient at present case was not hypertensive at presentation; advancing age, syncope epi- sode, possibilities of aortic rupture, and false hypotension due to aortic arc dissection were possible related factors with nonhypertensive status. In the following time, the patient has not accepted the emergent operation and has died 21 days after diagnoses of the giant Stanford type A aortic dissection. In conclusion, an aggressive surgical approach should be performed in patients with a history of AVR and mod- erate dilatation of the ascending aorta because of the rapid progression of the ascending aortic disease. Early recognition and diagnosis is essential for appropriate medical and con- secutive surgical therapy. References [1] F. A. A. Pieters, J. W. Widdershoven, A. C. Gerardy, G. Geskes, E. C. Cheriex, and H. J. Wellens, “Risk of aortic dissection after aortic valve replacement,” American Journal of Cardiology, vol. 72, no. 14, pp. 1043–1047, 1993. [2] J. Bachet, M. Pirotte, F. Laborde, and D. Guilmet, “Reoper- ation for giant false aneurysm of the thoracic aorta: how to reenter the chest?” Annals of Thoracic Surgery, vol. 83, no. 5, pp. 1610–1614, 2007. [3] R. Erbel, F. Alfonso, C. Boileau et al., “Diagnosis and man- agement of aortic dissection: recommendations of the Task Force on Aortic Dissection, European Society of Cardiology,” European Heart Journal, vol. 22, no. 18, pp. 1642–1681, 2001. [4] C. R. Bonnichsen, T. M. Sundt III, N. S. Anavekar et al., “Aneurysms of the ascending aorta and arch: the role of imag- ing in diagnosis and surgical management,” Expert Review of Cardiovascular Therapy, vol. 9, no. 1, pp. 45–61, 2011. [5] B. L. Milas and J. S. Savino, “Pseudoaneurysm of the ascending aorta after aortic valve replacement,” Journal of the American Society of Echocardiography, vol. 11, no. 3, pp. 303–306, 1998. [6] Z. Masuda, T. Murakami, E. Shishido, and M. Kuinose, “A rare cause of dissection of ascending aorta after aortic valve replacement,” Asian Cardiovascular and Thoracic Annals, vol. 16, no. 1, pp. e4–e6, 2008. [7] K. Prenger, F. Pieters, E. Cheriex, R. B. Griepp, and Marrone, “Aortic dissection after aortic valve replacement: incidence and consequences for strategy,” Journal of Cardiac Surgery, vol. 9, no. 5, pp. 495–499, 1994. [8] A. Modi, H. A. Vohra, M. Kaarne et al., “Long-term out- come following repair of acute type a aortic dissection 3 after previous cardiac surgery,” Interactive Cardiovascular and Thoracic Surgery, vol. 13, no. 4, pp. 386–391, 2011. [9] E. Weigang, C. A. Nienaber, T. C. Rehders, H. Ince, C. F. Vahl, and F. Beyersdorf, “Management of patients with aortic dissection,” Deutsches Arzteblatt, vol. 105, no. 38, pp. 639–645, 2008. [10] M. L. J. M. van de Wetering, L. J. Wagenaar, B. J. Bouma, and D. R. Koolbergen, “Giant pseudoaneurysm after aortic root re- placement,” Netherlands Heart Journal, vol. 18, no. 7-8, p. 381, 2010. [11] F. Enseleit, J. Gr u¨nenfelder, J. Braun, F. Matthews, R. Jenni, and B. van der Loo, “Formation of pseudoaneurysm after aor- tic valve replacement without previous endocarditis: a case- control study,” Journal of the American Society of Echocardiog- raphy, vol. 23, no. 7, pp. 741–746, 2010. [12] P. G. Hagan, C. A. Nienaber, E. M. Isselbacher et al., “The international registry of acute aortic dissection (IRAD): new insights into an old disease,” Journal of the American Medical Association, vol. 283, no. 7, pp. 897–903, 2000. [13] T. T. Tsai, C. A. Nienaber, and K. A. Eagle, “Acute aortic syndromes,” Circulation, vol. 112, no. 24, pp. 3802–3813, 2005. [14] B. A. Sharpe and M. Klompas, “Clinical manifestations of acute aortic dissection,” Journal of the American Medical Asso- ciation, vol. 288, no. 7, p. 828, 2002. [15] T. T. Tsai, E. Bossone, E. M. Isselbacher et al., “Clinical characteristics of hypotension in patients with acute aortic dissection,” American Journal of Cardiology, vol. 95, no. 1, pp. 48–52, 2005.