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------------------------------------------------ A 54-year-old man is evaluated during a routine examination. He is asymptomatic and exercises regularly without any limitations. Medical history includes hypertension and a bicuspid aortic valve with an enlarged aortic root (measuring 5.1 cm six months ago). Family history is unremarkable. His only medication is losartan.

On physical examination:
- Blood pressure: 122/74 mm Hg
- Cardiac examination: midsystolic ejection click and a grade 2/6 crescendo-decrescendo systolic murmur at the second right intercostal space
- The remainder of the examination is unremarkable.

Transthoracic echocardiogram findings:
- Normal left ventricular function
- Bicuspid aortic valve
- Mean gradient across the aortic valve: 20 mm Hg
- Aortic valve area: 1.6 cm²
- Ascending aorta: 5.1 cm
- Descending thoracic aorta: incompletely visualized

What is the most appropriate management for this patient?

1) Aortic valve replacement and ascending aortic repair
2) Ascending aortic repair
3) Dobutamine stress echocardiography
4) Repeat echocardiography in 6 months

Given his stable health status and asymptomatic conditions, the most suitable management for the 54-year-old man with a bicuspid aortic valve and an enlarged aortic root would be to repeat echocardiography in 6 months.

Explanation:

This 54-year-old man's case suggests a condition of a bicuspid aortic valve with an enlarged aortic root measuring 5.1 cm, which was diagnosed 6 months ago. Considering his medical history, symptoms, and latest physical examination, with blood pressure at 122/74 mm Hg and a grade 2/6 crescendo-decrescendo systolic murmur discovered at the cardiac examination, the most appropriate management would be the option 4: Repeat echocardiography in 6 months.

The reason behind this recommendation is that despite the presence of conditions like hypertension and an enlarged aortic root, his health remains stable, and he is asymptomatic, with an ability to exercise regularly without limitations. Under these circumstances, invasive interventions like aortic repair are not required, and the patient's case could be monitored with another echocardiogram after 6 months.

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