CASE

REPORTS

Bacterial

Endocarditis

Aorticocardiac

CESAR

A. CONDE,

with Ruptured Sinus of Valsalva and

Fistula

MD

MELLER, MD EPHRAIM DONOSO, MD, FACC SIMON DACK, MD, FACC

JOSE

New York. New York

A case is presented of bacterial endocarditis with a ruptured sinus of Valsalva and formation of an aorticocardiac fistula from the right coronary sinus into the right atrium and right ventricle. The pathologic, clinical and surgical aspects of bacterial endocarditis complicated by a ruptured sinus of Valsalva and an aorticocardiac fistula are analyzed. This complication of bacterial endocarditis is still uncommon, but alertness to its diagnosis makes possible early and successful surgical treatment.

Rupture of a sinus of Valsalva aneurysm is uncommon but several reports have outlined its pathophysiologic features and described its clinical recognition and management. l-7 Rupture of a sinus of Valsalva in the absence of a preceding aneurysm is a more unusual occurrence, and only three cases have been reported.8-10 Congenital aneurysms of the sinuses of Valsalva are frequently seen and occur in 3.5 percent of cases of congenital heart disease treated surgicallyrl; most often the aneurysms are associated with other congenital lesions, especially ventricular septal defect,3,7 coarctation of the aorta”*12 and biscupid aortic valve.3p4,13 They frequently rupture, usually into the right ventricle or right atrium, and are prone to infection and occasional subsequent rupture as we11.,7,5,12,14,15 Acquired aneurysms of the sinuses of Valsalva are less common. Before 1950 syphilis was considered the most frequent cause; in Jones and Langley’s collected series3 of 22 cases of acquired aneurysms of the sinuses of Valsalva, 17 were due to syphilis and 4 were considered secondary to bacterial endocarditis. The incidence of rupture is difficult to estimate because of the small number of reported cases. Aorticocardiac fistulas have frequently been reported in association with infected and noninfected congenital aneurysms.ls When associated with an acquired aneurysm the fistula is most frequently due to bacterial endocarditis with a septic aneurysm of a sinus of Valsalva.8~1”,17~25An aorticocardiac fistula without a preceding aneurysm is very unusual.8-10 Recently we studied a case of bacterial endocarditis complicated by rupture of a sinus of Valsalva into the right chambers of the heart without formation of an aneurysm. We describe this case and review previous reports on aorticocardiac fistula due to rupture of an infected sinus of Valsalva, with or without a preceding aneurysm. Case From the Division of Cardiology, Department of Medicine, Mount Sinai School of Medicine of the City University of New York, New York, N. Y. Manuscript accepted May 21, 1974. Address for reprints: Simon Dack, MD, The Mount Sinai Hospital, Division of Cardiology, Department of Medicine, 100th St. and Fifth Ave., New York, N. Y. 10029.

912

June 1975

The

Report

A 34 year old construction worker with a 10 year history of asymptomatic aortic stenosis was transferred to the Mount Sinai Hospital for further treatment of bacterial endocarditis. Six weeks before transfer he had had a dental extraction without antibiotic prophylaxis. Two weeks later he experienced malaise, anorexia, fever and loss of weight and was treated for 2 weeks with various orally administered antibiotic agents. His condition did not improve, and he was hospitalized in another institution, where examination revealed a temperature of 101.5“ F, pulse rate of 120/min and blood pressure of 95/60

American Journal of CARDIOLOGY Volume 35

BACTERIAL

mm Hg. There was no neck vein distension. A grade 316 systolic ejection murmur and a grade 2/6 diastolic decrescendo murmur were heard at the base. A splinter hemorrhage was present in the right index finger. The white blood cell count was 10,200 mm3 and the erythrocyte sedimentation rate was 70 mm in 1 hour. A chest roentgenogram was normal. Although several blood cultures were negative, treatment with penicillin and streptomycin was begun. One week after admission, rales were heard in both lungs, the systolic murmur at the base changed in quality, becoming harsh, and new splinter hemorrhages were seen. Oxacillin and digoxin were added to the treatment regimen. In the following days the blood urea nitrogen increased to 26 mg/lOO ml and the hematocrit decreased to 31 percent. Two weeks after admission he complained of pain in the right upper quadrant of the abdomen. A systolic thrill was felt at the left sternal border for the first time. Rales appeared in both lungs and the liver became pulsatile and tender, and was enlarged 4 cm below the right costal margin. He was transferred to the Mount Sinai Hospital. History revealed that during childhood he had had recurrent episodes of tonsillitis. A murmur of aortic stenosis was heard during a routine physical examination at age 24 years. There was no history of rheumatic fever, syphilis or hypertension. Physical examination on admission to this hospital revealed a pale and diaphoretic 34 year old man in moderate respiratory distress. The temperature was 103.8’ F, pulse rate 102/min, blood pressure 135/50 mm Hg in both arms and respirations 36/min. The skin was sallow, without petechiae, splinter hemorrhages or Osler’s nodes. The neck veins were fully distended at 60’ with prominent V waves. The carotid pulses had a weak upstroke and a rapid downstroke. Rales were heard in the lower third of both lungs. The point of maximal cardiac impulse was in the sixth intercostal space, 3 cm to the left of the midclavicular line. A systolic thrill at the lower left sternal border and a continuous thrill in the third interspace at the left sternal border were palpable. The first heart sound was markedly diminished. A summation gallop was present at the apex. A grade 516 continuous murmur with greater intensity during the second heart sound was heard along the left sternal border and radiated to the apex, axilla and aortic area. The spleen was not palpable. Laboratory studies disclosed a hemoglobin of 9.7 g/IO0 ml and a white blood cell count of 17,700 mm3 with 86 percent neutrophils. Serum glutamic oxaloacetic transaminase was 320 units, glutamic pyruvic transaminase 260 units and alkaline phosphatase 75 units. The prothrombin time was 19 seconds with a control value of 12 seconds. Partial thromboplastin time was 38 seconds, fibrinogen was 410 mg and bleeding time more than 15 minutes. Clotting factors VIII, IX and XI were normal. Results of the Venereal Disease Research Laboratory test were negative. Urinalysis and results of other routine chemistry determinations were normal. The chest roentgenogram revealed moderate cardiomegaly and pulmonary vascular congestion. The electrocardiogram disclosed a junctional tachycardia (rate 120/min) with incomplete atrioventricular (A-V) dissociation and a preexisting pattern of complete left bundle branch block. Administration of digoxin was discontinued. Blood cultures were taken and treatment with furosemide, penicillin, gentamycin and vitamin K was begun. Cardiac catheterization was performed 24 hours after admission (Table I). A marked increase in oxygen saturation at the right atria1 and right ventricular levels indicated a left to right shunt with a pulmonary to systemic flow

ENDOCARDITIS

TABLE

WITH RUPTURED AORTIC SINUS-CONDE

ET AL.

I

Cardiac Catheterization Findings O2Saturation

Pressure Site Inferior vena cava Superior vena cava Right atrium Right ventricle Pulmonary artery Pulmonary capillary Left ventricle Aorta Figures in parentheses

(%)

(mm Hg)

51 52

...

. a = 20;~ = 36 (18) 50/11 50/18 v = 47 (23) 160/32 94152 (77) indicate

78 84 84 ... 92 93

mean pressure.

ratio of 4:l. The pressure tracings indicated moderate aortic valve stenosis, and calcification was noted fluoroscopitally. The aortic root angiogram revealed immediate opacification of the right atrium and right ventricle and 4+ aortic regurgitation into the left ventricle. A right ventricular angiogram revealed mild to moderate tricuspid regurgitation. Surgical findings and treatment: On the basis of these findings and the progressive hemodynamic deterioration the patient was taken to the operating room. Platelets, fresh frozen plasma and Solu-Cortef@ were administered because of the prolonged bleeding time. During the operation it was found that all four cardiac chambers were enlarged and the aortic valve was heavily calcified and stenotic with fusion of the right coronary and noncoronary cusps. No aneurysmal dilatation of the sinuses of Valsalva was found. A fenestration of the right coronary sinus near the commissure of the noncoronary and right coronary cusps with a diameter of approximately 1 cm communicated with the right ventricle and the right atrium through the attachment of the septal leaflet of the tricuspid valve. There was significant attendant tricuspid regurgitation, but the valve appeared morphologically normal. The ruptured sinus of Valsalva was repaired with vertical mattress sutures reinforced with pledget material, and the septal leaflet of the tricuspid valve was reanchored to the septal anulus correcting the tricuspid insufficiency. The aortic valve was replaced with a Bjork-Shiley prosthesis. The postoperative course was uncomplicated and all signs of heart failure disappeared in the next 24 hours, The electrocardiogram revealed a prolonged P-R interval (0.24 second) and persistence of the left bundle branch block pattern. The six sets of blood cultures taken on admission grew anaerobic streptococci. Pathologic examination of the aortic valve revealed severe calcification, fibrosis, vegetations and gram-positive cocci. Antibiotic therapy was continued for 4 weeks. On discharge, the patient was receiving digoxin and Coumadine, had no symptoms and was free of signs of active bacterial endocarditis or congestive heart failure.

Discussion In 1840 Thurnam’ described 18 patients with 22 aneurysms of a sinus of Valsalva; his report included the first recorded case in which an aneurysm of the right aortic sinus ruptured into the right ventricle. In 1914 Atmar Smith2 reported two necropsy studies of

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913

BACTERIAL

ENDOCARDITIS

TABLE

II

Clinical

Studies of Bacterial

Reference Jones and Langley?

WITH RUPTURED AORTIC SINUS-CONDE

Endocarditis:

Sinus of Valsalva

Involvement

Total

Cases

Necropsies

Year

Cases

with BE

(no.1

1949

47

1951 1955

442 23

442 4

. .. 22

Dormer*8 Morgan and Blandzi Friedberg et aLa Vogler et aLaa

1958 1959 1961 1962

82 228 95 148

82 228 95 148

6 109

Blount3’ Lerner and Weinstein*6 Ramsey et aLa Cherubin and Neuz4 Dreyer and Field+

1965 1966 1970 1971 1973

12 25

endocarditis;

89

89

100

100

16 656 28

16 656 28

LCS = left coronary

SV Aneurysm

sv Rupture

11 RCS

7 RCS

5 NCS

3 NCS

..

4

Cates and Christie29 Oram and East”

BE = bacterial

ET AL.

7 LCS 0 23 1 3 0 0

57

1 LCS 0 23

1 RCS-RA 0 0

0 3 0

Remarks Bicuspid aortic valve (2 cases) Aorticocardiac fistula (6 cases) Aortic cusp rupture (2 cases) All ruptured into the right heart chambers ... ... ... One ruptured mycotic aneurysm of aorta . ...

Drug addicts

... 0

sinus; NCS = noncoronary

Drug addicts sinus; RA = right atrium;

RCS = right coronary

sinus; SV

= sinus of Valsalva.

patients with sinus of Valsalva aneurysms and referred to syphilis as “the most potent etiologic factor” in these cases. Today, because of the decreased incidence of syphilis, bacterial endocarditis is responsible for most acquired aneurysms of the sinuses of Valsalva.8,13~17-25 In 1955 Oram and East5 reviewed nine such cases of acquired aneurysms, four of which were attributed to bacterial endocarditis. In two cases associated congenital anomalies made it impossible to exclude a congenital origin of the aneurysms because of “the predilection of vegetations to form on any structural defect of the heart.”

Incidence

of Sinus of Valsalva

Rupture

Jones and Langley3 observed 6 cases of aorticocardisc fistula in their review of 47 cases of sinus of Valsalva aneurysms, but only 4 were due to bacterial endocarditis. In Oram and East’s report,5 only 4 of 23 cases of aorticocardiac fistula were secondary to bacterial endocarditis, and Dormer28 found only 1 case of rupture of the right coronary sinus into the right atrium in a review of 82 cases of bacterial endocarditis. Several other large clinical studies are remarkable for the absence of this complication (Table II). Necropsy cases: In a review of 348 reported cases of bacterial endocarditis36-38 there were no instances of rupture of a sinus of Valsalva despite the large percentage of patients who died with congestive heart failure secondary to valve dysfunction. However, several isolated reports of this complication have appeared4.13,‘7,18,24,39-41(Table III). Surgically treated cases: Surgery for complications of bacterial endocarditis with marked hemodynamic decompensation has become a definitive form

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of treatment. A review of the published cases reveals 16 definite cases of rupture of a sinus of Valsalva secondary to bacterial endocarditis7*8-10*12,1g-2s~4s-47 (Table IV). Windsor et a1.44 in 1972 reported 42 cardiac operations in patients with bacterial endocarditis, 15 performed urgently and 25 electively (the period between institution of antibiotic therapy and operation ranged from 2 months to 10 years). In the first group they found two cases of rupture of an aneurysm of the sinus of Valsalva, one into the right atrium and one into the right ventricle. In the second group sinus of Valsalva aneurysms were found on nine occasions and an associated fistula was discovered in three cases. Despite the presence of abscesses and fistulas, persistent infection postoperatively was seen in only one case of aorticocardiac fistula. Location of rupture: The location of the fistula and shunt produced by rupture of a sinus of Valsalva depends on which sinus has been involved by the infective process. Rupture of the right coronary sinus occurs most frequently. Rupture of the left coronary sinus occurs least frequently, but when it occurs it is usually due to bacterial endocarditis since rupture of this sinus is extremely unusual in congenital cases.48 The most frequent site of rupture of a sinus of Valsalva is into the right side of the heart, either to the right atrium or right ventricle.5,48 We found only one report, from a postmortem study, of rupture into both cavities due to bacterial endocarditis.sg Less frequently a sinus of Valsalva may rupture into the left ventricle,3*5*15*40 pulmonary artery,3*5 pericardium”~4~41and, in unusual circumstances, even into the pleural cavity3; the clinical presentation differs according to the type of fistula.

Volume 35

BACTERIAL

TABLE

ENDOCARDITIS

Studies of Bacterial

Endocarditis:

Sinus of Valsalva

Involvement

Cases with BE

Autopsies Year

Reference

(no.1

sv sv Aneurysms Rupture

Venning” Feldman et al.Xg Tosbach and Bainn Buford and PickardlO Jick et al.‘* Bristow et aL4*

1951 1956 1958 1959 1959 1960

7 1 1 1 1 1

6 1 1 1 1 1

7 1 1 1 1 1

4 1 1 1 1 1

Robinson and RuedyZ6 Cherubin et al.Bi CPC’3 Datta et aLZ4 Buchbinder and Robertg8

1962 1968 1970 1971 1972

20,770 36 1 1 45

267 36 1 1 45

0 0 1 3 0

0 0 1 0 0

Abbreviations

Surgical

ET AL.

III

Pathologic

TABLE

WITH RUPTURED AORTIC SINUS-CONDE

as in Table

Remarks Three cases with bicuspid aortic valve Rupture into right atrium and ventricle Calcific aortic stenosis Bicuspid aortic valve and coarctation of aorta Polycythemia vera with myeloid metaplasia Calcific aortic stenosis left coronary sinus ruptured to pericardium ... Drug addicts Bicuspid aortic valve Aortic insufficiency Left-sided bacterial endocarditis

II.

IV Studies of Bacterial

Endocarditis:

Sinus of Valsalva

Cases

Involvement Site of Rupture

sv Aneurysm

sv Rupture

1

1

1

1958 1963

1 2

1 2

0 2

March and Greenwoodd5 Stason et al.9

1966 1968

3 13

3 0

3 1

RCS-RV NCS- RA SV-RA RCS- RA

Symbas

1968

1

1

1

RCS-RV

Hatcher et al.23 Manhas et al.‘0 Gonzalez-Lavin et al.19 Sarot et al.41 Buckley et al.8 Kennedy47 Hatcher et al.20

1969 1970 1970 1970 1971 1971 1971

11 14 58 63 15 4 28

1 0 0 2 0 1 0

1 1 0 8 1 1 0

RCS-RV NCS-RA

Schumacker*z Crosby et al.21

1972 1972

4 19

4 1

0 1

Windsor

1972

42

11

5

Reference

Year

(no.)

Brown et al.42

1955

Glenn et al.12 Magidson and Kay7

and Par+@

et al.44

RV = right ventricle;

other abbreviations

as in Table

RCS-RV

No details RCS-RV No details

RCS-RV 2 RCS-RV 2 NCS-RA 1 RCS-RA

Remarks Probably congenital; recurrent endocarditis Coarctation of the aorta Congenital aneurysms

bacterial

Probably congenital Rheumatic heart disease with aortic insufficiency Mycotic ventricular septal defect, calcific aortic stenosis Same case reported by Symbas in 1968 Calcific aortic stenosis 6 cases with mycotic aneurysms of aorta 61 cases taken from the literature No details No details 1 case with mycotic ventricular septal defect Rheumatic heart disease insufficiency See text

with aortic

Il.

Clinical Features

The clinical findings of an aorticocardiac fistula due to rupture of an infected sinus of Valsalva are well illustrated by our patient’s course. After slight initial improvement in the patient’s condition during treatment for bacterial endocarditis, congestive heart failure suddenly developed, with clinical manifestations of a left to right shunt. Simultaneously a continuous thrill and a murmur occurred over the upper

left sternal border along with peripheral signs of aortic and tricuspid regurgitation. In their differential diagnosis of continuous murmurs in adults, March and Greenwood45 affirmed that rupture of the sinus of Valsalva ranked second, after persistent ductus arteriosus, as the most common cause of such murmurs. Chest pain was not a symptom of the rupture in our case although pain occurred in the right upper abdomen. Oram and East reported5 chest pain as an

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915

BACTERIAL

ENDOCARDITIS

WITH

RUPTURED

AORTIC

SINUS-CONDE

initial and transient symptom in 16 of 23 patients and Lockhart et al.49 found this symptom in 37 percent of 63 patients. However, in March and Greenwood’s series,45 pain did not occur in any of their cases. Electrocardiographic abnormalities: Abnormalities of the conduction system have been reported in association with this entity and are very well defined with types III and IV congenital aneurysms.‘* This association is thought to be due to involvement of the membranous ventricular septum. First degree and complete atrioventricular block may occur5J8m6” as well ‘as junctional tachycardia with A-V dissociat,ion.‘3J4,59,60 Since most of these patients are being treated with digitalis and diuretic agents for congestive heart failure, the diagnosis of digitalis intoxication is commonly made, as it was in our case. However, if the clinical setting makes the clinician suspect, involvement of the sinus of Valsalva, these electrocardiographic abnormalities would support the latter diagnosis, especially if digitalis is not being administered. Treatment Because of the marked hemodynamic decompensation emergency surgery was performed in our patient even before completion of a course of antibiotic drugs. After the operation his recovery was immediate, and within hours there were no signs of heart

ET AL

failure. Antibiotic treatment was continued for 4 weeks. The appropriate duration of antibiotic treatment after valve replacement in bacterial endocarditis has not been established but several reports8,55,56 have stated that a shorter than usual period of treatment can be successful. Despite the presence of first degree A-V block and left bundle branch block preoperatively and the site and extent of the operation, complete heart block was not seen postoperatively and a permanent pacemaker was not required as it has been in similar reported cases.13,57-5gThe patient remained asymptomatic and was discharged on a regimen of digitalis and Coumadin 4 weeks postoperatively. Fourteen months postoperatively, he is doing well. Because of the destructive changes produced by the infection it is impossible to exclude the possibility of a preexisting congenital aneurysm of a sinus of Valsalva after the formation of a fistula, especially in the presence of an associated bicuspid aortic valve and calcific aortic stenosis. However, the anatomic characteristics of an aneurysm were not present at the time of the operation. Our case illustrates the feasibility of successful emergency surgical treatment of rupture of a sinus of Valsalva in patients with bacterial endocarditis. Although such rupture is not a common complication of bacterial endocarditis, it can be lethal if it is not diagnosed and treated promptly.

References 1. Thurnam J: On aneurisms and especially spontaneous varicose aneurisms of ascending aorta and sinuses of Valsalva with cases. Trans Med Chir Sot Edinburgh 23:323-338, 1840 2. Smith WA: Aneurysm of the sinus of Valsalva. With report of two cases. JAMA 62:1878-1880, 1914 Br Heart J 11: 3. Jones M, Langley F: Aortic sinus aneurysms. 325-341. 1949 4. Venning GR: Aneurysms of the sinus of Valsalva. Am Heart J 4257-69, 1951 5. Oram S, East T: Rupture of aneurysm of aortic sinus (of Valsalva) into the right side of the heart. Br Heart J 17541-551, 1955 6. Edwards J, Burcheii H: The pathological anatomy of deficiencies between the aortic root and the heart including aortic sinus aneurysms. Thorax 12:125-139, 1957 7. Magidson 0, Kay JH: Ruptured aortic sinus aneurysms. Clinical and surgical aspects of seven cases. Am Heart J 65:597-606, 1963 8. Buckley M, Mundth E, Daggett W, et al: Surgical management of the complications of sepsis involving the aortic valve, aortic root and ascending aorta. Ann Thorac Surg 12:39 l-399, 197 1 R, Weinberg A, et al: Cardiac surgery in 9. Stason W, DeSanctis bacterial endocarditis. Circulation 38:514-523, 1968 L, et al: Open heart surgery 10. Manhas D, Hesael E, Winterscheid in infective endocarditis. Circulation 41:841-848, 1970 11. Taguchi K, Sasaki N, Matsura Y, et al: Surgical correction of aneurysm of the sinus of Vaisalva. A report of forty-five consecutive patients including eight with total replacement of the aortic valve. Am J Cardiol 23: 180-l 9 1, 1969 12. Glenn F, Stewart H, Engle M, et al: Coarctation of aorta complicated by bacterial endocarditis and an aneurysm of the sinus of Valsalva. Circulation 17:432-442, 1968 conference: Case records of the Massa13. Clinico-pathological chusetts General Hospital. N Engl J Med 283:1042-1050, 1970

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14.

15. 16.

17. 18.

19.

20.

21.

22.

23.

Volume 35

24.

25 26

Sakakibara S, Konno S: Congenital aneurysm of the sinus of Valsalva. Anatomy and classification. Am Heart J 63:405-424, 1962 Bjork V, Bjork L: Aneurysm of the sinus of Valsalva. J Thorac Cardiovasc Surg 50: 16-2 1, 1965 Gerbode F, Osborn J, Johnston B, et al: Ruptured aneurysms of the aortic sinuses of Valsaiva. Am J Surg 102:268-279, 1961 Tosbach S, Bain G: Acquired aortic sinus aneurysm caused by haemophilus aphrophilus. Am J Clin Pathoi 30:328-335. 1958 Jick H, Kasarjian P, Barsky M: Rupture of aneurysm of aortic sinus of Valsalva associated with acute bacterial endocarditis. Circulation 19:745-749, 1959 Gonzales-Lavin L, Scappatura E, Lise M, et al: Mycotic aneurysms of the aortic root. A complication of aortic valve endocarditis. Ann Thorac Surg 9551-561, 1970 Hatcher C, Symbas P, Logan W, et al: Surgical management of complications of bacterial endocarditis. Ann Surg 173: 10451052,197l Crosby I, Carrel1 R, Reed W: Operative management of valvular complications of bacterial endocarditis. J Thorac Cardiovasc Surg 641235-246, 1972 Shumacker H: Aneurvsm of the aortic sinuses of Valsalva due to bacterial endocarditis, with special reference to their operative manaoement. J Thorac Cardiovasc Surp 63:896-903, 1972 Hatcher C, Symbas P, Logan W, et al: Surgical aspects of endocarditis of the aortic root. Am J Cardioi 23:192-198, 1969 Datta B, Berry J, Khattri H: Infected aneurysm of sinus of Valsalva. Report of a case with involvement of all three sinuses. Br Heart J 33:323-325, 1971 Symbas P, Baldwin 6, Bchiant R, et al: Unusual complications of bacterial endocarditis. Br Heart J 33~664-670, 1971 Lerner PI, Weinstein L: Infective endocarditis in the antibiotic

BACTERIAL

era. N Engl J Med 274:199.259.323,388, 1966 27. Morgan W, Bland E: Bacterial endocarditis in the antibiotic era. With special reference to the later complications. Circulation 19:753-765, 1959 28. Dormer E: Bacterial endocarditis. Survey of patients treated between 1945 and 1956. Br Med J 1:63-69, 1958 29. Caters J, Christie R: Subacute bacterial endocarditis. A review of 442 patients treated in 14 centres appointed by the Penicillin Trials Committee of the Medical Research Council. Q J Med 20: 93-130,195l 30. Vogler WR, Dorney ER, Bridges HA: Bacterial endocarditis. A review of 148 cases. Am J Med 32:910-928, 1962 3 1. Blount JG: Bacterial endocarditis. Am J Med 38:909-922, 1965 32. Ramsey FIG, Gunnar RM, Tobin J: Endocarditis in the drug addict. Am J Cardiol 25:608-6 18, 1970 33. Friedberg CK, Goldman HM, Field LE: Study of bacterial endocarditis. Comparisons in ninety-five cases. Arch Intern Med 107:6-15, 1961 34. Cherubin CE, Neu HC: Infective endocarditis at the Presbyterian Hospital in New York City from 1938-1967. Am J Med 51:8396, 1971 35. Dreyer NP, Fields BN: Heroin-associated infective endocarditis. A report of 28 cases. Ann Intern Med 78:699-702, 1973 36. Robinson M, Ruedy J: Sequelae of bacterial endocarditis. Am J Med 32:922-928, 1962 37. Cherubin CE, Baden M, Kavaler F, et al: Infective endocarditis in narcotic addicts. Ann Intern Med 69: 1091-1099, 1968 38. Buchbinder NA, Roberts WC: Left-sided valvular active infective endocarditis. A study of forty-five necropsy patients. Am J Med 53:20-35, 1972 39. Feldman L, Friedlander J, Dillon R, et al: Aneurysm of the right sinus of xalsalva with rupture into the right atrium and into the right ventricle.. Am Heart J 51:314-324, 1956 40. Buford H, Pickard S: Unsuspected rupture of aortic sinus aneurysm into the right atrium. Am J Cardiol 3:404-410, 1959 4 1. Bristow JD, Parker B, Hang W: Hemopericardium following rupture of a bacterial aortic sinus aneurysm. Am J Cardiol 6:355358, 1960 42. Brown JW, Heath MB, Whitaker W: Cardio-aortic fistula. A case diagnosed in life and treated surgically. Circulation 12: 819-826, 1955 43. Sarot I, Weber D, Schechter D: Cardiac surgery in active, primary infective endocarditis. Chest 57:58-64, 1970 44. Windsor H, Golding L, Shanahan M: Cardiac surgery in bacteri-

ENDOCARDlTlS

WITH RUPTURED AORTIC SINUS-CONDE

ET AL.

al endocarditis. J Thorac Cardiovasc Surg 64:282-29 1, 1972 45. March JE, Greenwood W: Rupture of the sinus of Valsalva. A study of eight cases with discussion on the differential diagnosis of continuous murmurs. Am J Cardiol 18:827-836, 1966 46. Symbas P, Parr J: Early surgical treatment for acute pneumococcal aortic valvulitis with aortic insufficiency, acquired ventricular septal defect, and aortico-right ventricular shunt. Ann Surg 167:580-585, 1968 47. Kennedy JH: Discussion in Ref. 8 48. Sawyers J, Adams JE, Scott W: Surgical treatment for aneurysms of the aortic sinuses with aortico-atrial fistula. Surgery 41:26-42, 1957 49. Lockhart A, Scebat L, Lenegre J: Etude clinique des aneurysms congenitaux ruppus des sinus de Valsalva. Arch Mal Coeur 57:508-52 1, 1964 50. Davidson HG, Fabricus J, Hulsfeldt E: Five cases of congenital aneurysm of the aortic sinuses (of Valsalva) and notes on the prognosis. Acta Med Stand 160:455-463, 1958 51. Lillehei CW, Stanley P, Varco RL: Surgical treatment of ruptured aneurysm of the sinus of Valsalva. Ann Surg 149:459472, 1957 52. Morrow A, Baker R, Hanson HE, et al: Successful surgical repair of a ruptured aneurysm of the sinus of Valsalva. Circulation 16:533-539, 1957 53. Spencer F, Blake H, Bahnson H: Surgical repair of ruptured aneurysm of sinus of Valsalva in two patients. Ann Surg 152: 963-968, 1960 54. McGoon D, Edwards J, Kirklin J: Surgical treatment of ruptured aneurysm of aortic sinus. Ann Surg 147:387-392, 1958 55. William T, Viroslav J, Knight V: Management of bacterial endocarditis-1970. Am J Cardiol 26:186-191. 1970 56. Okies JE, Williams T, Howell J, et al: Valvular replacement in bacterial endocarditis. Cardiovasc Res Cent Bull 8: 126-134, 1970 57. Katz 0, Cooper J, Frfeden J: Bacterial endocarditis presenting as complete heart block with paradoxical (left to right) pulmonary emboli. Am Heart J 85:108-l 12, 1973 58. Meshel JC, Wachtel H, Graham J: Bacterial endocarditis presenting as heart block. Am J Med 48:254-255, 1970 59. Wang K, Gobel F, Gleason D, et al: Complete heart block complicating bacterial endocarditis. Circulation 46:939-947. 1972 60. Roberts NK, Somerville J: Pathological significance of electrocardiographic changes in aortic valve endocarditis. Br Heart J 31:395. 1969

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