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enestration of the aortic valve is not an uncommon malformation, and appears as an oval hole immediately below the free edge of the cusp near its commissural attachment. Fenestration of the aortic cusp is not considered to have any pathological significance, and is rarely associated with aortic regurgitation, but we are operating on an increasing number of cases of massive aortic regurgitation in which large fenestrations play an important role in the pathogenesis of regurgitation. We present 6 cases in which the clinicopathological findings were analyzed. Methods PatientsDuring the past 9 years at Iwaki Kyoritsu General Hospital, more than 200 aortic valves have been replaced because of aortic regurgitation caused by idiopathic annular dilatation, infected endocarditis, rheumatic valvular disease or congenital bicuspid valve. Of these patients, 6 cases with large aortic valve fenestrations (Fig 1), which played an important role in producing massive aortic regurgitation, were evaluated from the clinical and pathological viewpoints. None of them showed systemic connective tissue disease or annuloaortic ectasia. The interval since onset was defined as the time span to surgical treatment from the appearance of new aortic regurgitant murmur, the Circulation Journal Vol.68, May 2004first experience of cardiac symptoms or echocardiographic detection of aortic regurgitation. Left ventricular hypertrophy was defined electrocardiographically by the QRS voltage criteria including RI + SIII ≥2.5 mV, R in aVf >2.0 mV, S in V1 ≥2.4 mV, R in V5 or V6 >2.6 mV, and R in V5 or V6 + S in V1 >3.5 mV. The aortic annular diameter (AAD), left ventricular diastolic dimension (LVDd), and left ventricular systolic dimension (LVDs) were measured by 2-dimensional echocardiography in the parasternal long-axis view. The severity of the aortic regurgitation was graded as trivial (I), mild (II), moderate (III) or severe (IV) using color flow mapping in the apical view of transthorac-

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