An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

Between January, 1975 and June, 1990, 67 patients underwent surgical treatment for infective endocarditis at our hospital. Of 67 patients, 27 patients showed active endocarditis at the time of operation. In these 27 patients, 20 had active endocarditis of the native valve (NVE), and the seven had active prosthetic valve endocarditis (PVE). The interval between onset of infective endocarditis and operation ranged from 7 to 252 days (mean, 36 days). In the operative results, 3 of 20 patients (15%) with NVE and 2 of 5 patients (40.0%) with PVE died before discharge from the hospital. According to analysis of preoperative hemodynamic state and bacteriological data, the determinant factors of operative mortality and morbidity were preoperative NYHA functional classification, the interval between onset of infection and operation, and annular destruction (annular abscess). Patient's age, preoperative renal function, positive blood culture, the site of infection, and positive culture or stain of the surgically excised valve did not play an important role to determine operative mortality and morbidity. It is our conclusion that all patients with infective endocarditis who develop progressive congestive heart failure and echocardigraphical extravalvular infection despite medical treatment, should have prompt valve replacement.

A case of 41-year-old man with large candidal vegetation on the tricuspid valve was reported. He was presented with high fever and newly developed heart murmur. Four months before admission, he had suffered from head trauma which required intravenous hyperalimentation and injection of multiple antibiotics through catheter indwelling the superior vena cava. On admission, echocardiogram showed large vegetation on the tricuspid valve, although blood cultures were sterile. At operation, tricuspid valve was replaced with St. Jude Medical prosthesis because large vegetation developed from the anterior tricuspid leaflet was confirmed. Candida albicans was detected by microscopic examination of the vegetation. The total of 1500mg of Amphotericine-B were administered intravenously after operation. His postoperative course was uneventful. We discussed about the availability of echocardiogram for diagnosis and the effectiveness of a combination of chemotherapy and valve replacement for treament of fungal endocarditis.