emella morbillorum (G. morbillorum), which is a nutritive variant of Streptococcus and was formerly classified as Streptococcus morbillorum, is an anaerobic to aerotolerant Gram-positive coccus. It is part of the commensal flora of the upper respiratory tract and the intestinal tract, and infections caused by this organism are unusual. We present a case of recurrent an active aortic valve endocarditis caused by G. morbillorum resulting in massive regurgitation, which was successfully treated surgically. Previously reported cases are also reviewed. Case ReportA 55-year-old man with persistent fever and nocturnal dyspnea was referred to hospital. He had a history of noninsulin dependent diabetes mellitus and type B hepatitis. Without any history of rheumatic fever, he had been diagnosed as having aortic regurgitation 35 years prior, and he had a history of infective endocarditis caused byhemolytic streptococcus, which was treated 5 years prior in another hospital with several different antibiotics with bacteriological cure. However, he had developed agranulocytosis because of gentamycin sulfate and piperacilin sodium therapy, and then suffered acute renal failure from interstitial nephritis following the administration of cefoperazon sodium. Fosfomycin and minocycline hydrochloride was able to be used without any side effects. The cardiac catheterization data showed a normal left end-diastolic pressure of 6 mmHg. Upon admission to hospital, his temperature was 39.3°C, blood pressure was 130/58 mmHg, and the heart rate was regular at 88 beats/min. He had extensive caries destruction of the teeth. Osler's nodes or splinter hemorrhage was not detected. On auscultation, a to-and-fro murmur with an intensity of Levine 3/6 was heard at the Erb's area. Dilatation of the neck vein was detected at the Fowler's position. A bounding pulse was palpable in the left femoral artery, but pulsation of the right femoral artery was not. Hepatosplenomegaly or pretibial edema was not observed.Laboratory examination showed a leukocyte count of 9,600 cells/m 3 , a hematocrit of 28.2%, and a hemoglobin of 9.3 g/dl. C-reactive protein (CRP) was 5.19 mg/dl. Urinaly-

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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A patient with a thrombosed mechanical valve underwent valve re-replacement during which a tumor of the left ventricular outflow tract with the typical macroscopic and microscopic characteristics of a papillary fibroelastoma was successfully removed surgically. The 60-year-old woman had undergone isolated mitral valve replacement with a St Jude Medical 29-mm valve for mitral regurgitation 15 years ago. The present admission was for investigation of dyspnea on exertion. Two-dimensional transthoracic echocardiography demonstrated a posteroseptal, pedunculated mass, measuring 1.3x1.0 cm, in the outflow tract of the left ventricle, mild mitral regurgitation and slight aortic stenosis.

Spontaneous detachment of the aortic valve commissure (ie, avulsion of a commissure) is a rare cause of acute massive aortic regurgitation that follows a rapidly deteriorating clinical course. The aortic valve commissure between the non-coronary and right coronary cusps detached from the aortic wall in a 79-year old man with ascending aortic aneurysm. Emergency aortic valve replacement and aneurysmoplasty were successfully performed; histopathology of the aorta and aortic valve showed cystic medial necrosis and myxomatous degeneration, respectively. Preoperative transthoracic echocardiography showed an eccentric massive regurgitant jet at the site of the prolapsing cusps with a vegetation-like echodense mass, and transesophageal echocardiography showed the prolapsing non-coronary and right coronary cusps conjoined by the commissural tissue. It was the precise echocardiographic evaluation of the avulsion that enabled sucessful emergency aortic valve surgery.