Healed Aortic Valve Endocarditis and Fenestrations

Clinical History

This 18 year old male was admitted to hospital with a 14 week history of malaise, weakness and joint pain. There was a past history of rheumatic fever 11 years previously. Following the development of a petechial rash and some aphasia, he was referred here for further management. Examination revealed a febrile, pale, sweaty boy, BP 185/10 mm Hg, pulse 98 and collapsing. There was 1.5 cm of jugular venous congestion and the apex beat was in the 7th left intercostal space 12 cm from the mid-sternal line. A harsh systolic thrill and murmur were present at the apex. In the aortic area a harsh systolic and blowing diastolic murmur were also heard and transmitted down the left border of the sternum. The spleen was palpable. Pistol shot femoral pulsation was present. The patient was treated with penicillin and digitalis and following improvement was sent to Caulfield Hospital where he stayed for 6 weeks. He was transferred back to this hospital with a 1 week history of anorexia, malaise and insomnia. Dyspnoea increased and despite treatment he died 9 days following re admission.

Pathology

The specimen is of a greatly enlarged heart sliced to display the left ventricular cavity, mitral and aortic valves. The left ventricular wall is thickened (23 mm) and dilated. The aortic valve is thickened, the edges of the cusps fused for a distance of 1 cm. The anterior cusp of the valve (that is, the cusp on the right) shows a centrally placed circular deficit 0.5 cm in diameter. The surrounding portion of the cusp is particularly thickened for a distance of 3-4 mm. The left posterior cusp shows a fenestration near the left free edge, 1.5_cm in diameter. These deficits have clean edges but several nodules 1-2 mm in diameter are present on the cusps. There is an area of endocardial roughening just below the right posterior aortic cusp with some adherent fibrinous material. What can be seen of the mitral valve shows some thickening and thrombus formation on the chordae. The pericardium appears thickened and slightly opaque. This is an example of healed endocarditis of the aortic valve with fenestration, possibly congenital, of the cusps.