Reassessment of Graham Steell murmur using platinum electrode technique.

Abstract

TheGrahamSteell murmurofrelative pulmonary regurgitation hasbeenreassessed using adirect technique involving injection ofascorbic acid into thepulmonary artery byneedle puncture andsensing with aplatinum electrode intheright ventricle. Whenthis technique wasusedin5casesofsuspected GrahamSteell murtnur, pulmonary regurgitation wasfound inall5,while aortic regurgitation wasdemonstrated inoneandwasnot assessed inoneother. These results arediscussed inrelation toother reports concerning this murmur.Inour experience, ahighly selected groupofpatients, withhigh orveryhigh pulmonary artery pressure andusually, considerably dilated pulmonary artery canbeidentified where theleft sternal border murmurcanbereliably predicted toemanate fromthepulmonary valve andthus torepresent aGrahamSteell murmur. After GrahamSteell (I888) described themurmur nowknownbyhisname,theexistence oftheentity ofpulmonary regurgitation associated withpulmonaryhypertension duetoacquired mitral valve disease wasaccepted formanyyears. However, within thepasttwodecades, muchevidence has accumulated tosuggest that inthevastmajority of cases, theearly diastolic murmuraudible attheleft sternal border isduetoaortic regurgitation (Runco andBooth, I963) andthat theGrahamSteell murmur,while notnon-existent, isarareentity. Inalarge series ofcases ofacquired rheumatic valvular disease withmoderate tosevere pulmonary hypertension seenatChristian Medical College Hospital, theauthors became convinced that asmall proportion ofsuchcases could clearly beconsidered tohaveaGrahamSteell murmur.Thisinvestigation wascarried outtoconfirm orrefute theimpressionthatincertain carefully selected cases, pulmonaryregurgitation canbereliably diagnosed as theorigin oftheleft sternal border early diastolic murmur. Inordertogainobjective evidence concerning thepresence orabsence ofpulmonary regurgitation, a technique usinginjection ofascorbic acidby direct needle puncture ofthepulmonary artery withdetection ofanyincompetence byaplatinum electrode placed intheright ventricle wasde