-Lavin, L. (1977). Thorax, 32,[619][620][621][622] Rupture of the normal aortic valve after blunt chest trauma. Rupture of the normal aortic valve after blunt trauma to the chest is seen infrequently. With the ever-increasing incidence of car Examination on admission showed an acutely ill young man with rapid respirations: blood pressure, 140/60 mmHg; pulse rate, 110/minute. Grade III/VI systolic and diastolic murmurs were again audible along the left sternal border. Breath sounds were diminished in the left lung. The chest radiograph showed interstitial densities through both lobes of the left lung and, although pulmonary contusion was suspected, early pulmonary oedema could not be ruled out (Fig. 1). An electrocardiogram showed non-specific ST-segment and T-wave changes. Cardiac cathieterisation disclosed no intracardiac shunts. Pressure The patient was operated upon with a diagnosis of severe aortic regurgitation due to non-penetrating traumatic rupture of the aortic valve leaflets. During cardiopulmonary bypass with hypothermic anoxic arrest the right coronary cusp of the aortic valve was found to be partially avulsed from the aortic annulus; the left coronary cusp was completely avulsed as was the intercoronary commissure (Fig. 2). The aortic valve was excised and a size 19 mm porcine xenograft valve' was in-

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SUMMARY Emergency aortic valve replacement was performed during an attack of acute rheumatic fever in a 12-year-old black boy. He had an uneventful recovery and has remained asymptomatic 27 months after operation. In the light of this experience and that of others, one might conclude that the decision to operate on these patients should be based on the severity of the haemodynamic derangement rather than on the state of activity in the rheumatic process.Notwithstanding the general belief that active rheumatic heart disease is a relative contraindication to cardiac surgery, recent reports have shown the value of valvular replacement in selected patients with acute rheumatic fever (Tinunis et al., 1966;Gersony et al., 1968;Kloth et al., 1969;. Certain children with rheumatic fever have an extremely poor prognosis with medical therapy (Taranta et al., 1962;Harris et al., 1966), and guidelines can be established to single out patients who will need and greatly benefit from early surgical intervention . In this communication we report a patient who had successful aortic valve replacement during an episode of recurrent acute rheumatic fever which produced severe aortic regurgitation and acute left ventricular failure. Case reportA 12-year-old black boy was admitted on 1 March 1974. He had a past history of acute rheumatic carditis and arthritis at the age of 8 years. Because of allergy to penicillin, he was discharged on erythromycin and aspirin. He was lost to follow-up until three weeks before the present admission when he developed fever and fatigue, with rising erythrocyte sedimentation rate (ESR) and antistreptolysin 0 (ASO) titre. Throat cultures were positive for beta-haemolytic streptococcus. Three days before admission to hospital, he developed arthralgia and chest pain.At admission, examination revealed an ill-looking boy with a temperature of 38'9°C; blood pressure, 114/50 mmHg; pulse, 116 per minute; respiratory rate, 28 per minute. Tenderness, without swelling or inflammatory signs, was noticed over the right elbow and both knees. Examination of the cardiovascular system revealed a grade 4/6 full diastolic murmur in the aortic area, and a grade 2/6 pansystolic murmur at the apex with radiation to the left axilla. Spleen and liver were not enlarged and peripheral oedema was absent. Laboratory investigations revealed an ESR of 64 mm/hour and ASO titre of 833 Todd units. C-reactive protein was positive. A test for sicklecell trait was negative. Chest x-ray film showed moderate cardiomegaly with some evidence of pulmonary congestion (Fig. 1). The electrocardiogram was unremarkable except for sinus tachycardia. Phonocardiogram showed the previously mentioned murnurs. Echocardiography showed a slight increase in ventricular cavity and left ventricular wall thickness. The left atrium was also slightly enlarged. He was placed on bed rest; digoxin, 0 125 mg daily after full digitalisation was obtained; and frusemide, 10 to 20 mg a day as treatment for heart failure. The patient was also placed on aspirin, 600 mg e...

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