Consulting cardiologist arrives: He reviews the history and testing and is still convinced the patient has heart ischemia. He recommends thrombolytic therapy, as his diagnosis remains cardiac ischemia, probably secondary to coronary artery disease. He also considers the emergency room physician’s differential diagnosis. Although the CT scan (highly specific test) has ruled out pulmonary embolism, the prominent aortic valve shadow is worrisome. He requests a transthoracic echocardiogram (TTE). This shows a widened mediastinum and the aortic valve is dilated to 4.5 cm.