Rupture of the Aortic Valve Due to Strain*
OTTO M . SPURNY, M .D . and MASAUKI HARA, M .D .
Little Rock, Arkansas
~ttE clinical picture of rupture of the aortic
j valve secondary to strain or trauma has been
recognized for many years . Only in recent
years has it been possible to attempt the surgical
correction of such lesions . Recently we have
had the opportunity to observe a patient with
rupture of the aortic valve following strain .
Surgical repair of the defect was attempted .
Even though this patient did not survive the
procedure, the case is being reported since
surgical intervention seems to offer the only
chance to halt an otherwise progressive and
eventually fatal course .
CASE REPORT
A sixty-two year old farm laborer (No . 17-08-30)
suddenly had an episode of severe substernal pain
radiating to the left scapula and down the left side of
his back on October 10, 1959, while carrying a 25
pound block of ice . The pain subsided after a few
minutes . The patient then developed progressive
shortness of breath and subsequently coughed up
frothy pink sputum- A physician treated the patient
with digitalis and diuretics without definite improve-
ment . The patient was referred to the University of
Arkansas Medical Center on October 20, 1959 to be
evaluated for a possible ruptured aortic cusp .
The patient stated that he had been in excellent
health all his life except for gonorrhea in 1912 and
influenza in 1918 . The patient specifically denied
any history of syphilis or rheumatic fever . A
physician had told him in 1955 that he had hyper-
tension .
On admission his blood pressure was 150/50 tom . Hg
in the right arm . The pulse was 100 per minute
and regular . The respirations were 26 per minute
and tie weighed 126 pounds . The temperature was
98 .4 F . His vital capacity was 2 .6 L . with a rapid
flow . The patient appeared dyspneic but was in no
acute distress . Funduscopic examination revealed
arteriolar narrowing and A-V nicking . In the supine
position the neck veins were distended and filled from
below . There was an exaggerated pulsation of both
carotid arteries, Dullness and decreased breath
sounds were present over both lung bases, Examina-
* From the Departments of Medicine and Surgery, University of Arkansas Medical Center, Little Rock, Arkansas .
JULY 1961
tion of the heart revealed the point of maximal im-
pulse 3 cm . lateral to the left midclavicular line in
the sixth intercostal space . The rhythm was regular .
A middiastolic thrill was palpable at the apex . Over
the base a grade 2 systolic murmur, followed by an
accentuated second aortic sound and a grade 3 high-
pitched diastolic decrescendo murmur, were heard .
A low-pitched rumbling grade 3 middiastolic murmur
was audible over the apex. The liver edge was
palpated 7 cm, below the right costal margin . 'the
peripheral pulses were equal in both arms and had a
water hammer quality . Dumziez' sign was elicited
over the femoral arteries . There was slight bilateral
pretibial edema .
Urinalysis revealed no abnormalities . The hemo-
globin was 11 .2 gm . per cent and the hematocrit was
35 per cent . A serologic test for syphilis (VDRL)
was negative . The blood urea nitrogen was 23 mg .
per cent . The venous pressure was equivalent to 120
mm . of saline with rise to 230 mm . on pressure over
the liver . The circulation time (Decholin,si arm to
tongue) was nineteen seconds,
Roentgenograms of the chest showed congested lung
fields and bilateral pleural effusion . The aortic
shadow did not appear enlarged . The heart was en-
larged, predominantly in the region of the left
ventricle (Fig . 1) .
An electrocardiogram revealed a sinus mechanism
with a rate of 90 per minute and changes suggestive
of left ventricular hypertrophy and digitalis effect
(Fig . 2) . There was no evidence of a recent or remote
myocardial infarction .
Course : On a regimen consisting of restricted ac,
tivity, limited sodium intake and digitalis, the patient
lost 17 pounds in the next twelve days with considera-
ble subjective and objective improvement The
patient was then discharged from the hospital with
the clinical diagnosis of a ruptured aortic cusp . He
became progressively short of breath despite strict
adherence to his cardiac regimen . the venous pres-
sure on a clinic visit on January 4, 1960 was equiva-
lent to 180 mm . of saline with rise to 250 mm . on
hepatic pressure . His circulation time (arm to
tongue) was thirty-four seconds . The patient was
readmitted m the hospital on January 11, 1960 . The
cardiac findings were unchanged . He again made
some improvement on a strict cardiac regimen . A
125


126 Spurny and Hara

Fie . 1 . Chest film which shows enlargement of the left ventricle and pulmon
congestion .

..... . ... . . . .. . . . .. . . . .. . . .. . . ... . . . . . . . . .. ... . . .. . . . . . . ... . . ...

a
2 31 4

Fie . 2. Electrocardiogram exhibiting left ventricular hypertrophy and digitalis effect

THE AMERICAN JOURNAL OF CARDIOLOGY


Rupture of the Aortic Valve
Fm . 3. Retrograde aurtogram which reveals rcllux of dye into the left ventricle
indicating aortic valvular incompetency .
retrograde aortogram (Fig . 3) showed reflux of dye from
the aorta into the left ventricle . No evidence of a
dissecting or localized aneurysm was seen .
Surgical Findings and Results : On January 26, 1960
an attempt was made to repair the valvtdar defect
using a Kay-Cross pump-oxygenator . The ascending
aorta was dilated, measuring 6 cm . in diameter, but
free of any inflammatory reaction suggestive of a
recent dissecting aneurysm . A diastolic thrill was
present in the left ventricle . Extracorporeal per-
fusion was instituted at an estimated flow rate of 62
cc ./kg ./minute . This maintained the arterial pres-
sure in the range of 75 to 105 mm . Hg . In the initial
eight minutes of the bypass procedure the venous re-
turn exceeded the arterial output by approximately
2,300 cc . of blood . A longitudinal J-shaped incision
JULY 1961
127
was made in the base of the aorta revealing a linear
rent 6 mm . long in the anterior half of the left pos-
terior aortic leaflet running parallel and about 1 .5
mm . medial to the annulus (Fig . 4) . The tear
crossed the free edge of the leaflet near the commis-
sure and extended proximally and anteriorly for a
distance of 6 mm . in an oblique direction through the
intima of the aorta . The leaflets were slightly
thickened but otherwise normal in appearance and
seemed to close adequately after the rent had been
repaired with several No . 4-0 arterial silk sutures .
The aorta was partly sutured after which the rest of
the opening was occluded by a Satinsky clamp and
the aortic clamp released to permit perfusion of the
coronary arterial bed . The heart began to beat
strongly within a period of two to three minutes .
128 Spurny and Hara
FIG . 4 .Drawing illustrating tear in the anterior portion
of the left coronary cusp .
The procedure had taken about fifteen minutes to
this point but complete extracorporeal perfusion was
continued for an additional ten to twelve minutes to
permit the heart to recover from the effects of is-
chemic arrest with decompression of the chambers
being achieved through vents previously placed in
both atria . The remainder of the aortotomy was
sutured during this time . The cardiac action ap-
peared strong and the atrial vents were occluded and
partial cardiac bypass instituted . A brief period of
bypass was reinstituted to facilitate closure of a small
leak in the posterior aspect of the aortotomy when it
was observed that the heart had ceased beating and
that the arterial and venous blood was exceedingly
dark . A hasty check revealed that the oxygen inlet
tube had become obstructed . Oxygen was intro-
duced directly into the oxygenating chamber and
extracorporeal perfusion continued for another thirty
minutes in an attempt to resuscitate the heart . De-
spite adequate perfusion of the coronary arteries and
repeated attempts at defibrillation, the heart could not
be permanently revived .
COMMENTS
Cases of rupture of the aortic valve due to
strain or trauma have been reported sporadi-
cally for over one hundred years . In 1925
Howard reviewed the data of 112 cases re-
ported from 1830 to 1925 and added another
case of his own,' The diagnosis was proved by
autopsy in forty-eight cases .
In sixty cases rupture was considered to be
due to muscular strain and in the remaining
cases secondary to trauma or unstated causes .
All except one of the cases due to strain had
occurred in men whose ages ranged from
twenty to sixty years with an increased inci-
dence in the fourth and fifth decades . Usually
only one cusp was affected, most commonly
the anterior leaflet, but involvement of two
cusps was reported occasionally . At autopsy
the valve was considered to be otherwise "nor-
mal" in only seven, or 23 per cent of the cases.
The majority of the protocols described the
valve as thickened, atheromatous or even cal-
careous .
The most common initial symptom is severe
pain within the chest occurring during physical
exertion . The pain is described as acute and
agonizing and may be associated with a sudden
tearing sensation within the chest . It is pri-
marily in the precordium or cpigastrium and
usually radiates to the neck and left shoulder
and sometimes into the back between the
shoulder blades . The patient may become
immediately conscious of a "roaring or buzzing
sensation" in his chest . Dyspnea occurs usually
immediately after the accident . The clinical
picture is characterized by the suddenness of
the onset of symptoms in a previously healthy
subject and the rapid development of pro-
gressive intractable heart failure together with
the circulatory signs of free aortic regurgita-
tion . The musical quality of the aortic diastolic
murmur has been repeatedly emphasized .
Several authors, however, have detected mur-
murs of this character more commonly in aortic
insufficiency secondary to syphilis or bacterial
endocarditis 2.a
The prognosis will vary with the size of the
tear and the degree of valvular insufficiency
produced . In the great majority of reported
cases the clinical course has been one of rapidly
progressing cardiac failure with death occurring
within months .
Because of the poor prognosis Bean and
Schmidt 4 questioned in 1953 the value of dis-
covering rupture of the aortic valve during life,
other than for the enhancement of the clini-
cian's pride in his diagnostic astuteness . Bean
also suggested that this injury represented an
ideal situation for surgical intervention . Leon-
ard, Harvey and Hufnagel 5 in 1955 were able
to report such an attempt in a seventeen year
old boy (with traumatic rupture of the aortic
valve) . They inserted a plastic valve into the
descending aorta . Even though the clinical
picture was complicated by a left to right shunt
at the ventricular level, the patient was asymp-
tomatic and doing heavy labor fourteen months
THE AMFRICAN JOURNAL OF CARDIOLOGY

Rupture of the Aortic Valve
after surgery . Dimond et al' reported a case
of post-traumatic aortic insufficiency in a pa-
tient with Marfan's syndrome in whom surgical
repair was unsuccessfully attempted . It would
seem that surgical intervention should be
attempted as early as possible in this disorder
since otherwise the prognosis is extremely
grave .
SUMMARY
A case of rupture of the aortic valve due to
physical strain is presented . Surgical repair
of the defect utilizing a cardiac bypass pro-
cedure was attempted but was unsuccessful .
A short discussion of the clinical picture of this
disorder is added and emphasizes the necessity
for attempted repair of this defect to avoid the
usual rapidly progressing cardiac failure and
death .
JULY 1961
129
REFERENCES
1 . HOWARD, C . P. Aortic insufficiency due to rupture
by strain of a normal aortic valve . C,anad..A
.J M .,
19 : 12, 1928 .
2 . CRLFAND . D . and BEI .t .ET, S . The musical murmur
of aortic insufficiency ; clinical manifestations ;
based on a study of 18 cases . Am . J . M . Se ., 221
644, 1951 .
3. STEMso.IDGn, V . A ., HEJTMANCI%, M. R. and HERR-
MANN, G . R . Unusual musical murmurs of an-
terior cusp aortic regurgitation . Am . Heart J ., 48 :
163, 1954 .
4. BEAN, W . B, and ScisanDr, M. C . Rupture of the
aortic valve : disappearing diastolic pressure as
diagnostic sign . J.A .M.A ., 153 : 214, 1953 .
5 . LEONARD, J . J ., HARVEY, W . P . and HVFNAGET ., C . A.
Rupture of the aortic valve : a therapeutic ap-
proach . New England J. Med ., 252 : 208, 1955 .
6. DIMMND, );. G ., LARSEN, W . E ., JOHNSON, W . B . and
KETTLE, C . F . Post-traumatic aortic insufficiency
occurring in Marfan's syndrome, with attempted
repair with a plastic valve. New England .1 . Mrd .,
256 : 8 . 1957 .