Murmur Of Aortic Regurgitation Research Articles

Improvement in the management of suspected acute aortic syndrome in the emergency room through a clinical algorithm and study of predictive factors

Background and objectiveAcute aortic syndrome (AAS) is uncommon and difficult to diagnose, with great variability in clinical presentation. To develop a computerized algorithm, or clinical decision support system (CDSS), for managing and requesting imaging in the emergency department, specifically computerized tomography of the aorta (CTA), when there is suspicion of AAS, and to determine the effect of implementing this system. To determine the factors associated with a positive radiological diagnosis that improve the predictive capacity of CTA findings. Materials and methodsAfter developing and implementing an evidence-based algorithm, we studied suspected cases of AAS. Chi-squared test was used to analyze the association between the variables included in the algorithm and radiological diagnosis, with 3 categories: no relevant findings, positive for AAS, and alternative diagnoses. Results130 requests were identified; 19 (14.6%) had AAS and 34 (26.2%) had a different acute pathology. Of the 19 with AAS, 15 had been stratified as high risk and 4 as intermediate risk. The probability of AAS was 3.4 times higher in patients with known aortic aneurysm (P = .021, 95% CI 1.2–9.6) and 5.1 times higher in patients with a new aortic regurgitation murmur (P = .019, 95% CI 1.3–20.1). The probability of having an alternative severe acute pathology was 3.2 times higher in patients with hypotension or shock (P = .02, 95% CI 1.2–8.5). ConclusionThe use of a CDSS in the emergency department can help optimize AAS diagnosis. The presence of a known aortic aneurysm and new-onset aortic regurgitation were shown to significantly increase the probability of AAS. Further studies are needed to establish a clinical prediction rule.

Mejora en el manejo de la sospecha del síndrome aórtico agudo en urgencias mediante un algoritmo clínico y el estudio de factores predictivos

Background and objectiveAcute aortic syndrome (AAS) is uncommon and difficult to diagnose, with great variability in clinical presentation. To develop a computerized algorithm, or clinical decision support system (CDSS), for managing and requesting imaging in the emergency department, specifically computerized tomography of the aorta (CTA), when there is suspicion of AAS, and to determine the effect of implementing this system. To determine the factors associated with a positive radiological diagnosis that improve the predictive capacity of CTA findings. Materials and methodsAfter developing and implementing an evidence-based algorithm, we studied suspected cases of AAS. Chi-squared test was used to analyze the association between the variables included in the algorithm and radiological diagnosis, with 3 categories: no relevant findings, positive for AAS, and alternative diagnoses. Results130 requests were identified; 19 (14.6%) had AAS and 34 (26.2%) had a different acute pathology. Of the 19 with AAS, 15 had been stratified as high risk and 4 as intermediate risk. The probability of AAS was 3.4 times higher in patients with known aortic aneurysm (P=.021, 95% CI 1.2–9.6) and 5.1 times higher in patients with a new aortic regurgitation murmur (P=.019, 95% CI 1.3–20.1). The probability of having an alternative severe acute pathology was 3.2 times higher in patients with hypotension or shock (P=.02, 95% CI 1.2–8.5). ConclusionThe use of a CDSS in the emergency department can help optimize AAS diagnosis. The presence of a known aortic aneurysm and new-onset aortic regurgitation were shown to significantly increase the probability of AAS. Further studies are needed to establish a clinical prediction rule.

Development of a Computerized, Evidence-Based Decision Support System for Computed Tomography Assessment in Acute Aortic Syndrome in the Emergency Department

Purpose: To develop a computerized algorithm, or Clinical Decision Support System (CDSS), for managing and requesting imaging in the emergency department, specifically Computerized Tomography Angiography (CTA) of the aorta, when there is suspicion of AAS, and to determine the effect of implementing this system. To determine the factors associated with a positive radiological diagnosis that improve the predictive capacity of CTA findings. Methods: After developing and implementing an evidence-based algorithm, we studied suspected cases of AAS. Chi-squared test was used to analyze the association between the variables included in the algorithm and radiological diagnosis, with three categories: no relevant findings, positive for AAS, and alternative diagnoses. Results: 130 requests were identified; 19 (14.6%) had AAS and 34 (26.2%) had a different acute pathology. Of the 19 with AAS, 15 had been stratified as high risk and 4 as intermediate risk. The probability of AAS was 3.4 times higher in patients with known AA (p = 0.021, 95% CI 1.2-9.6) and 5.1 times higher in patients with a new aortic regurgitation murmur (p = 0.019, 95% CI 1.3-20.1). The probability of having an alternative severe acute pathology was 3.2 times higher in patients with hypotension or shock (p = 0.02, 95% CI 1.2-8.5). Conclusion: The use of a CDSS in the emergency department can help optimize AAS diagnosis. In our hospital it improved AAS management and the diagnostic yield of CTA.

Murmurs other than the early diastolic murmur in aortic dissection.

The purpose of this review is to draw attention to the presence and significance of murmurs other than the murmur of aortic regurgitation, in patients with aortic dissection. For that purpose, a literature search was conducted using Pubmed and Googlescholar. The search terms were "dissecting aneurysm of the aorta", "systolic murmurs", "ejection systolic murmurs", "holosystolic" murmurs, "continuous murmurs", and "Austin-Flint" murmur. Murmurs other than the murmur of aortic regurgitation, which were associated with aortic dissection, fell into the categories of systolic murmurs, some of which were holosystolic, and continuous murmurs, the latter attributable to fistulae between the dissecting aneurysm and the left atrium, right atrium, and the pulmonary artery, respectively. Mid-diastolic murmurs were also identified, and these typically occurred in association with both the systolic and the early diastolic murmurs. Among patients with systolic murmurs clinical features which enhanced the pre-test probability of aortic dissection included back pain, stroke, paraplegia, unilateral absence of pulses, interarm differences in blood pressure, hypertension, shock, bicuspid aortic valve, aortic coarctation, Turner's syndrome, and high D-dimer levels, respectively. In the absence of the murmur of aortic regurgitation timely diagnosis of aortic dissection could be expedited by increased attention to parameters which enhance pretest probability of aortic dissection. That logic would apply even if the only murmurs which were elicited were systolic murmurs.

Ревматическая полимиалгия в клинических рекомендациях 2018–2020 гг. Часть II: диагностика васкулита

Совершенствование диагностики ревматических болезней пожилых людей и заболеваний аорты— актуальные задачи медицины. В патогенезе аневризм, расслоений, разрывов аорты важна роль воспаления и структурных изменений ее стенки, которые выявляют с помощью визуализирующих методов. Ведению ревматической полимиалгии, гигантоклеточного артериита, аневризм аорты посвящен ряд международных рекомендаций. С аортитом сопряжено до 40% случаев ревматической полимиалгии. Клиническое подозрение на него основано на выявлении асимметрии артериального давления и пульса, шума аортальной регургитации, сосудистых шумов, персистенции ревматической полимиалгии, воспалительной боли в спине, области таза и нижних конечностях. В 2020 году именно позитронно-эмиссионная томография/компьютерная томография рекомендована Итальянским обществом ревматологов для диагностики васкулита при ревматической полимиалгии во вторичном звене и Европейской федерацией головной боли для диагностики крупнососудистого гигантоклеточного артериита в неврологической практике. Приведен обзор рекомендаций Европейской ассоциации ядерной медицины, Общества ядерной медицины и молекулярной визуализации и Американского общества ядерной кардиологии по применению позитронно-эмиссионной томографии с фтордеоксиглюкозой в сочетании с компьютерной томографией (ангиографией) при васкулитах крупных сосудов и ревматической полимиалгии (2018). Они сопоставлены с клиническими руководствами, другими рекомендациями обществ ядерной медицины и новыми научными данными. Описана процедура исследования и подготовка к нему. Рассмотрены критерии оценки васкулита, предложенные для клинической практики и для клинических исследований, а также факторы, влияющие на результаты теста и их интерпретацию (атеросклероз, диабет, возраст, индекс массы тела, уровни гликемии и маркеров острой фазы). В рекомендациях обоснована польза применения позитронно-эмиссионной томографии и ее сочетания с компьютерной томографией для выявления экстракраниального васкулита и ценность компьютерной томографии-ангиографии на разных стадиях болезни. Требует усиления доказательная база стандарта времени экспозиции фтордеоксиглюкозы и пользы сочетания позитронной эмиссионной томографии с компьютерной томографией-ангиографией, в том числе для выявления рецидивов васкулита и мониторинга терапии. Необходим консенсус по раннему выполнению исследования, стандартизация оценок его результатов, обеспечение реимбурсации, внедрение новых методик визуализации сосудов черепа. В перспективе доказательный подход к ведению васкулита дополнит терагностика.

A novel cardiac spectral envelope extraction algorithm using a single-degree-of-freedom vibration model

A novel cardiac spectral envelope extraction method was developed to acquire the optimal envelope information in the frequency domain to differentiate normal heart sounds and valvular heart disorders for further analysis. This automatic algorithm was based on the vibration model of a mass–spring–damper system. To acquire the best spectral envelope information from both a normal heart sound signal and an aortic regurgitation murmur signal, the morphological influence of two analytical parameters, the natural frequency p (range: 1–100Hz) and the damping factor ζ (range: 10–500%), on the single-degree-of-freedom model was evaluated using the root mean square error. The cardiac spectral envelope curve could be optimized at the natural frequency of 35±5Hz and the damping factor of 70±8%. The spectral envelope extracted by the single-degree-of-freedom model showed more informative and efficient morphological characteristics than that extracted by an autoregressive power spectrum density model reported previously.

The men who picked the truant notes in heart sounds

Since the invention of stethoscope by Rene Laennec, auscultation has become sine qua non of clinical examination, especially for cardiovascular system. Many clinical signs are named after the first describer, as a tribute to their efforts. So is true for cardiac murmurs. Sir Graham Steell was a British cardiologist who described the high pitched diastolic murmur of pulmonary regurgitation. Diastolic murmur of severe aortic regurgitation is named after American physician, Austin Flint, who actually disapproved eponyms. American physician Richard Clarke Cabot and his colleague Locke described early diastolic murmur of severe anemia, which is thought to be due to high flow in left coronary artery. The name of Carey Coomb, a British cardiologist, is associated with mid-systolic murmur of mitral valvulitis in acute rheumatic fever. Left anterior descending arterial stenosis sometimes produces an early diastolic murmur and it was first described by American physician William Dock. The machinery murmur of patent ductus arteriosus was first described by George Alexander Gibson. Key-Hodgkin murmur is the diastolic murmur of aortic regurgitation, named after Thomas Hodgkin and Charles Ashton Key. French pediatrician Henri Louis Roger described the holosystolic murmur of ventricular septal defect and his name is also associated with Maladie de Roger. Sir George Frederic Still, an English paediatrician, whose name is associated with juvenile idiopathic arthritis described the innocent functional murmur mostly heard in children. It was Louis Gallavardin, a French physician, who described the phenomenon of dissociation of musical component and noisy component of aortic stenosis. Though the popularity of such eponyms are on wane due to advent of phonocardiography and ECHO Doppler, one hopes some newer descriptions of murmurs due to changing profile of cardio-vascular diseases will emerge in near future.

Postoperative Electrocardiogram in a Man with the Marfan Syndrome

A 53-year-old man with the Marfan syndrome had undergone aortic valve replacement with a Bjork-Shiley prosthesis for aortic regurgitation at another hospital 15 years earlier. At the same operation he had a Kay-type suture plication tricuspid annuloplasty of the posterior-septal commissure. He came to the cardiology clinic for preoperative clearance for inguinal hernia repair. An aortic regurgitation murmur was noted, and he admitted to exertional dyspnea. An electrocardiogram showed sinus rhythm, a normal P-R interval, and right bundle branch block. An echocardiogram revealed a dilated ascending aorta, severe aortic regurgitation due to a perivalvular leak, normal left ventricular systolic function, and pulmonary arterial hypertension with tricuspid regurgitation and a large right ventricle. Because of these findings he underwent a Cabrol procedure, i.e., a composite aortic valve and root replacement with reimplantation of the coronary arteries, and tricuspid valve replacement. Mechanical valves were used in both the aortic and tricuspid positions. A postoperative electrocardiogram showed sinus arrhythmia, at a rate of 88 beats/minute, that was completely dissociated from a regular, accelerated junctional rhythm, at a rate of 67 beats/minute, with right bundle branch block and left anterior fascicular block (Figure). Alternatively, the subsidiary pacemaker could have been in the left posterior fascicle. Many of the P waves were positioned where they would be expected to be conducted to the ventricles, but the perfectly regular ventricular rhythm indicated that none were. Thus, there was some degree of atrioventricular block. The relatively rapid subsidiary pacemaker may have contributed to the complete atrioventricular dissociation, and the atrioventricular block may have not been complete. Marriott has referred to this as “block-acceleration dissociation” (1). Figure Electrocardiogram recorded in the early postoperative period. See text for explication. Aortic valve replacement requires the surgeon to operate in close proximity to the atrioventricular conduction tissue (2). As a consequence, atrioventricular block and/or an accelerated junctional rhythm may develop, and the chances of this are greater if, as in this patient, the anatomy has been distorted by a prior operation. The rhythm disturbance in this patient is a combination of the two, i.e., a conduction disturbance in combination with increased automaticity. Other conditions, such as inferior myocardial infarction or digitalis toxicity, also may produce block-acceleration atrioventricular dissociation (1). Complete atrioventricular block is virtually never persistent in patients with inferior myocardial infarction or digitalis toxicity, and consequently these patients do not require permanent electronic pacing. In contrast, complete atrioventricular block developing after aortic valve surgery may be persistent, and those patients require permanent pacing (3, 4).

A Unique Case of Quadricuspid Aortic Valve With Coronary Artery and Descending Aorta-to-Pulmonary Artery Fistulae

46-year-old man with well-controlled hypertension pre-sented with dyspnea, palpitations, and a murmur of aortic regurgitation. Echocardiography revealed a quadricuspid aortic valve (QAV) with 4 equal-sized cusps and enlarged left main coronary artery ostium (Figure 1A). On additional imaging, an unusual flow was seen entering the proximal main pulmonary artery from the lateral aspect just distal to the pulmonic valve (Figure 2A and Movie I in the online-only Data Supplement). A QAV with moderate aortic regurgitation (Movie II in the online-only Data Supplement) and a coronary-pulmonary artery fistula were diagnosed by echocardiography. Computed tomography confirmed the presence of QAV (Figure 1B) and a small-cal-iber vessel that originated from the left main coronary artery, coursed superiorly (Figure None.2B), and ended in a larger confluence of anomalous vessels that communicated with the pulmonary artery (Figure 2C). Other vessels contributing to this conflu-ence originated from the descending aorta and followed a very tortuous course (Figure 2D1 through 2D3). A 3-dimensional reconstruction shown in Figure 2E demonstrates the descend-ing aorta-to-pulmonary artery fistula and coronary artery-to-pulmonary artery fistula draining into a large confluence. Thus, a unique anomaly in combination with QAV was diagnosed.QAV is a rare malformation, with an estimated incidence of 0.003% to 0.043% of all congenital heart disease.

An uncommon complication of an aortic root aneurysm

Platypnea-orthodeoxia syndrome (POS) is an uncommon clinical syndrome consisting of dyspnea and deoxygenation accompanying a change from a recumbent to an upright position. The underlying mechanism requires both anatomical and functional features, which result in a right-toleft interatrial shunt. We present a case of POS in an elderly patient with patent foramen ovale (PFO) and aortic root dilatation. A 79-year-old woman, with a history of a healed breast cancer 30 years before, was admitted to the emergency room with increasing dyspnea and shortness of breath last month, especially when moving from supine to the erect position. On physical examination, in a recumbent position, she was eupneic, well perfused and her arterial blood oxygenation was 94 %. When standing up, she referred dyspnea and developed peripheral cyanosis with an arterial blood oxygenation of 63 % despite oxygen administration. On auscultation, a diastolic murmur of aortic regurgitation was heard. A chest X-ray showed dilatation of the aortic root without signs of heart failure. The electrocardiogram did not show abnormalities. An urgent transthoracic echocardiogram was performed revealing normal ventricles, moderate aortic regurgitation and the presence of a dilated ascending aorta and aortic root (48 mm) which compressed extrinsically the right atrium with a significant chamber reduction. Estimated systolic pulmonary pressure was 37 mmHg. An interatrial septum aneurysm was observed, and when agitated saline was injected intravenously in a lying position (Fig. 1a), no microbubbles were identified in left atrium. Nevertheless, when standing up, the aortic root compressed sharply the right atrium, and microbubbles appeared immediately in the left atrium (Fig 1b.), confirming the existence of a right-to-left intracardiac shunt. A CT scan proved dilatation of the aortic root with severe compression of the right atrium without signs of intrapulmonary arteriovenous malformations. The patient underwent closure of the PFO with a percutaneous device (Fig 1c). During the procedure, an aortography was performed showing the ascending aorta and aortic root dilatation and enabling its measurement. There was no evidence of right-to-left residual shunt in the echocardiographic control one week later. The patient was discharged and two years later remains asymptomatic. POS is a rare underdiagnosed clinical entity, first described by Burchell [1], consisting of dyspnea and hypoxemia induced by upright posture that is relieved by recumbency [2]. Its pathophysiology is controverted and has been related to hepatic, pulmonary and cardiac diseases. Nowadays, the most recognized underlying condition is the presence of a right-to-left interatrial shunt in the presence of a PFO or an atrial septal defect (ASD) [3]. In normal circumstances, due to the higher pressure of the left atrium, in the presence of either a PFO or an ASD, there is left-to-right shunt. When conditions that increase right atrial pressure and modify the position of the atrial septum concur, redirection of the flow from the vena cava towards the septum in the upright posture is possible. These conditions can be cardiac (pericardial effusion, constrictive pericarditis), pulmonary (arteriovenous malformations), hepatic (cirrhosis) or vascular (aortic aneurysms) in origin [2–4]. J. M. Montero Cabezas (&) M. de Riva Silva R. Martin Asenjo F. Hernandez Hernandez 12 de Octubre University Hospital, Madrid, Spain e-mail: jmmonterocabezas@hotmail.com

Giant Syphilitic Aortic Aneurysm

A 76-year-old man with a history of syphilis presented with progressive dyspnea and leg swelling. Auscultation of the precordium was notable for a diastolic blowing murmur of aortic regurgitation, and there was ECG evidence of left ventricular hypertrophy.

Disintegration of a Stentless Valved Conduit Causing Contained Rupture of the Aortic Root

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 40-year-old-man required, in 2007, the implantation of a stentless valved conduit for destructive aortic endocarditis. In 2009, he presented with dyspnea and a new aortic regurgitation murmur, but no

Acute myocardial infarction with cardiogenic shock in a patient with acute aortic dissection

Diagnosing acute Stanford type A aortic dissection with the uncommon involvement of the left main coronary artery(LMCA) remains challenging for the emergency physician because it can resemble acute myocardial infarction with cardiogenic shock. The following case report illustrate this infrequent but critical situation. A 52-year-old woman with a history of hypertension awakened with acute retrosternal chest pain accompanied by nausea and vomiting. She was referred to our hospital for primary coronary intervention because of acute myocardial infarction with cardiogenic shock. Coronary angiography indeed revealed LMCA occlusion. Subsequently successful percutaneous coronary intervention with stent implantation was performed, followed by immediate clinical improvement of the patient. Soon after admission at the coronary care unit, severe chest pain, hypotension, and electrocardiographic signs of diffuse myocardial ischemia relapsed. Control coronary angiography,however, showed no in-stent thrombosis. Review of clinical examination revealed an aortic regurgitation murmur. Because of this dynamic pattern of (1) signs of acute myocardial ischemia, (2) relapse of hemodynamic collapse, and (3) unaltered control coronary angiography together with the confirmed aortic regurgitation at transthoracic echocardiography, the patient was suspected of having aortic dissection. Transesophageal echocardiography revealed Stanford type A aortic dissection with severe eccentric aortic regurgitation and no pericardial effusion. Emergent valve-sparing aortic replacement was performed. The patient recovered completely. In this case, the lifesaving element was primary coronary intervention with stenting of the LMCA preventing extensive myocardial damage followed by a surgical correction of the aorta.

Acute Valvular Regurgitation

Acute severe valvular regurgitation is a surgical emergency, but accurate and timely diagnosis can be difficult. Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific. Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure. Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves. Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers. Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology. The guidelines recommend valve surgery for symptomatic patients with aortic or mitral regurgitation, including those with acute regurgitation.1–3 The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery. Causes of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1). Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved. The majority of causes of acute regurgitation present as an acute or subacute event. However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis. Acute regurgitation of either the aortic or mitral valve may result from procedural …

Index of Suspicion

Index of Suspicion

Circumferential aortic dissection

An adolescent otherwise healthy male presented with acute onset chest pain. Physical examination was remarkable for early diastolic murmur of aortic regurgitation. Transthoracic and subsequently transoesophageal echocardiography revealed aortic dissection...

Horton's aortitis

Giant cell arteritis is the most common systemic vasculitis in people over the age of 50 years. Ischaemic manifestations are well known. 'Occult' manifestations as aortic aneurysmal disease need consideration. The incidence of aortic aneurysm and/or dissection is about 18.5 per 1000 person-years at risk (18.9 in Lugo(4) and 18.7 in Olmsted County(3)). Predictive factors are hypertension, polymyalgia rheumatica, coronaropathy, and hyperlipaemia. Another factor is the apparition of an aortic regurgitation murmur as in this case. So, these patients should be monitored by echocardiography.

ENTEROCOCCAL ENDOCARDITIS PRESENTING WITH SUDDEN RIGHT ARM WEAKNESS IN A 73‐YEAR‐OLD MAN

ENTEROCOCCAL ENDOCARDITIS PRESENTING WITH SUDDEN RIGHT ARM WEAKNESS IN A 73‐YEAR‐OLD MAN

Pathologic and clinical features of infectious endocarditis

Infectious endocarditis is a systemic disease associated with high morbidity and mortality. Clinical recognition and effective management is challenging, but insights can be gleaned from relevant pathologic features. Risk factors include subaortic stenosis, possibly certain other congenital anomalies, and bacteremia. Auscultation can provide clues regarding valvular involvment, particularly when a diastolic left basilar murmur of aortic valve regurgitation is present. Aortic valve vegetations and insufficiency may also alter femoral arterial pulse characteristics. Echocardiography may facilitate diagnosis, particularly with aortic valve lesions, but may not be able to distinguish between small mitral valve vegetations and early chronic degenerative valve disease. Vegetative lesions develop along edges of valve closure on the ventricular aspect of the aortic valve and the atrial surface of atrioventricular valves. They may extend across valve leaflet, from valves to adjacent left atrial endocardium, interventricular or interatrial septum, or chordae tendineae. Vegetations can be friable and frequently embolize to spleen, kidney, and left ventricle — often before clinical recognition of the disease. Valvular insufficiency develops as a consequence of valvular vegetations, necrosis, perforation, or rupture of the chordae tendineae. Histopathologic appearance varies with respect to duration of disease and antimicrobial therapy. These factors influence the amount of necrotic material, blood clot, fibrin, and inflammatory cells which make up the vegetations. Bacteria are not always identified in valvular lesions, especially following antibacterial therapy, but may be detected in other organs. Common sequellae include congestive heart failure, sepsis, arrhythmias, and systemic organ infarction.

Subclinical rheumatic valvitis: a long-term follow-up

In order prospectively to investigate the frequency and evolution of subclinical valvitis, we selected 40 consecutive patients suffering their initial attack of rheumatic fever, seen in our clinic from 1992 to 1994, and followed-up until 2001, with a mean period of follow-up of 8.1 years, and a standard deviation of 0.6 year. We also assembled a matched control group of 37 healthy children and adolescents. We discovered a murmur of mitral regurgitation in 28 (70.0%) of the patients. In 3 (7.5%) of these patients, there was also a murmur of aortic regurgitation. In the group of 28 symptomatic patients, Doppler echocardiography showed mitral regurgitation in all, and aortic regurgitation in 17. In the group of 12 patients without clinical evidence of cardiac involvement, Doppler echocardiography identified mitral regurgitation in 2, isolated in one and associated with aortic regurgitation in the other. Thus, the frequency of subclinical valvitis was 16.7%. In patients with subclinical valvitis only the aortic regurgitation regressed during the period of follow-up. In the group of 28 symptomatic patients, mitral regurgitation disappeared in 6 (21.4%), aortic regurgitation in 7 of the 17 having this feature (41.2%), while 2 patients (7.1%) developed mitral stenosis. The sensitivity and specificity of cardiac auscultation were, respectively, 93.3%, with 95% confidence intervals between 72.3% and 97.4%, and 100%, with 95% confidence intervals between 65.5% and 100%, for the diagnosis of mitral regurgitation, and 16.7%, with 95% confidence intervals between 4.4% and 42.3%, and 100%, with 95% confidence intervals between 81.5% and 100%, for that of aortic regurgitation. We conclude that the Doppler echocardiogram is an important means of diagnosing and assessing the evolution of subclinical rheumatic valvar lesions, which are not always transient. We suggest that Doppler echocardiography should be performed in all patients with acute rheumatic fever. Subclinical valvitis should be considered as mild carditis, provided that strict criterions are observed in the differential diagnosis from physiological regurgitation, and Doppler echocardiographic findings are analyzed in the context of the other manifestations of the disease.