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A 74 year old male, who had been treated for hypertension, was admitted to the emergency department with chest pain of four hours duration radiating to his back. The initial electrocardiogram showed signs of myocardial ischemia with ST segment depression in anterolateral and inferior leads. Blood pressure was 85/55 mmHg, heart rate was 105 bpm on his physical examination. Minimal (grade 2/6) decrescendo diastolic murmur was audible on the left sternal edge. In addition, bibasilar crackles were detected on pulmonary auscultation. Emergency two-dimensional echocardiography showed that severe ascending aortic dissection with an intimal flap prolapsing into the left ventricular despite normal left ventricle size and systolic function. Transesophageal echocardiography demonstrated circumferential intimal disruption that started just above the aortic root and extended distally through the aortic arch and into the carotid artery. The circumferential intimal flap was prolapsing into the left ventricle during diastolic phase, causing severe aortic regurgitation and resulting in diastolic occlusion of both coronary arterial ostia (Figure A, Figure B, Figure C). The patient underwent a combined coronary artery bypass grafting and replacement of the aortic valve, ascending aorta and aortic arch.