Continuous Murmur Research Articles

Aorta-right atrial tunnel: an interesting type of a congenital coronary artery anomaly.

An 18-year-old girl with an aortico-right atrial tunnel originating from the left sinus of Valsalva, in which the left anterior descending and circumflex coronary arteries arose independently from the different parts of the tunnel, was reported. In the differential diagnosis of continuous murmur, this type of tunnel should be taken into consideration. Surgical approach should be offered.

Ductal spasm during performance of transcatheter ductal occlusion

Transcatheter patent ductus arteriosus (PDA) occlusion is a staple of pediatric catheterization laboratories. We present the phenomenon of significant PDA spasm to prevent failure to occlude a hemodynamically significant duct. Transcatheter techniques have evolved, allowing safe and effective occlusion of PDAs in younger and smaller patients. Neonatal care is evolving with increasing survival at younger gestational ages. Premature infants often have PDAs, so the proportion of formerly premature children referred for transcatheter ductal occlusion will likely rise. We reviewed all transcatheter PDA occlusions performed at our institution since 2001 (N = 331). Retrospective data included: gestational age, age at catheterization, precatheterization echocardiographic parameters, PDA size (after spasm relief), device specifications, and most recent follow-up data. Seven cases were identified. Median age was 12 months, median gestational age was 28 weeks. All were born prematurely. All PDAs were restrictive and six had left-heart volume overload. All patients were examined by the interventional cardiologist and had ductal murmurs. When reauscultated (three of seven), murmurs were absent during spasm. Once spasm relieved, PDA diameters ranged from 1.5 to 8 (median 2) mm. All patients accommodated a 6-mm-or larger-Amplatzer device. No significant complications occurred and all patients were well at follow-up. Ductal spasm occurs during transcatheter occlusion and may be an unrecognized cause of procedural failure. The phenomenon seems to occur in children born prematurely, and can occur after infancy. Loss of a continuous murmur confirms the diagnosis. Care should be taken to avoid device under-sizing when spasm occurs.

Holt–Oram syndrome with aortopulmonary window – a rare association

A 4-month-old male infant presented with recurrent cough for 2 months. He had a shortened right upper limb with absent right thumb and continuous murmur in the left parasternal area. The X-ray showed an absent radius and the first metacarpal and phalyngeal bones on the right side. Echocardiogram revealed aortopulmonary window and small secundum atrial septal defect. Aortopulmonary window was successfully treated by device closure. Holt-Oram syndrome with aortopulmonary window is an extremely rare association.

An Unusual Cause of Congestive Heart Failure in a Young Woman

BackgroundCongestive heart failure (CHF) is a common Emergency Department (ED) disorder that accounts for >5 million ED visits annually. Although quite rare, patent ductus arteriosus (PDA) is a serious cause of CHF that if left untreated can lead to life-threatening sequelae, such as hypertensive pulmonary vascular disease, endarteritis, and aneurysms of the ductus. ObjectiveTo discuss a case of PDA leading to CHF that illustrates one of the common complications of untreated PDA. Case ReportA 35-year-old woman presented to the ED with a 2-month history of shortness of breath, dyspnea on exertion, decreased exercise tolerance, and orthopnea. The physical examination revealed a 4/6 continuous machine-like murmur. In the presence of new CHF and an atypical murmur, a transthoracic echocardiogram was performed that confirmed the diagnosis of PDA. She underwent an uncomplicated percutaneous closure of the ductus with significant improvement in her symptoms. ConclusionsPersistent PDA in adulthood is a rare but important cause of CHF with significant morbidity and mortality if not appropriately diagnosed and treated.

Anterograde Percutaneous Coronary–Cameral Fistula Closure Employing a Guide-in-Guide Technique

A 33-year-old woman was evaluated for palpitations and a continuous murmur. Echocardiography demonstrated a dilated vascular structure posterior to the aortic root. Coronary angiography revealed a coronary–cameral fistula originating from the left main coronary artery emptying into the right

Auscultation of the Heart - III

The essential difference between a sound and a murmur is that the former is due to sudden alteration in the speed of blood flow whereas a murmur results from turbulence developing in the blood stream. A murmur is usually of longer duration and of higher frequency than a sound. The principal factors which influence turbulence are the velocity of flow, the density and viscosity of the blood and the diameter of the vessel. Another important factor is that a narrowed orifice, as from valvular stenosis, will give rise to eddies beyond the obstruction. A similar effect is produced by a relatively narrow vessel opening into a wider one as in dilatation of the first part of the aorta or pulmonary artery.Murmurs may be heard in systole or diastole or may appear to be continuous throughout systole and diastole.Diastolic and continuous murmurs are always due to organic disease but a systolic murmur may be present not only without any functional disability but without any clinical, radiographic or electrocardiographic evidence of organic heart disease.

Iatrogenic Aortopulmonary Window and Pulmonary Artery Dissection Secondary to Aortic Cannulation

We present a case of a 23-year-old man with Shone’s complex, including bicuspid aortic valve, coarctation of the aorta status post neonatal repair and subsequent stent placement, mitral valve stenosis status post valve repair, and eventual replacement 1 year before the current presentation. A noncontrast thoracic computed tomography scan was performed after his mitral valve replacement to investigate a persistent pleural effusion. The scan revealed an unusual area of high and low attenuation within the proximal pulmonary arterial system, and a contrast-enhanced computed tomography study was recommended for additional evaluation. However, given that the patient was asymptomatic with unremarkable physical examination, follow-up study was not performed until ≈1 year later when he was noted with a new continuous murmur on physical examination and an echocardiogram revealed continuous flow arising from the distal ascending aorta into the pulmonary artery on two-dimensional color Doppler (Figures 1A …

Coronary Artery to Right Atrium Fistula Associated With First Degree Atrioventricular Block: A Rare Association.

A 40 year-old man with no significant past history except for asymptomatic 1st degree heart block presented for general health screen. Clinical examination revealed a loud continuous murmur with diastolic accentuation in the left precordium, noncollapsing pulse, and no differential pulses in the upper and lower limbs. The ECG showed normal sinus rhythm with PR interval of 220 milliseconds. Transthoracic echocardiogram (Figure ​(Figure1)1) showed a dilated right coronary artery that was enlarged, forming multiple saccular aneurysms distally that drain into the roof of right atrium. The right heart was normal in size and function. CT angiogram (Figure ​(Figure2)2) later confirmed the presence of a coronary artery fistula from the right coronary artery draining into the right atrium. Right coronary artery is dilated and the distal segment of the RCA is tortuous and aneurismal. Nuclear myocardial perfusion imaging showed no inducible ischemia during exercise stress. He declined cardiac catheterization, and was advised for corrective surgery. This case illustrated a rare saccular aneurysm formation in a right coronary artery to right atrium (coronary-cameral) fistula associated with 1st degree atrioventricular (AV) block. Coronary arteriovenous fistula (CAVF) arises as a persistence of sinusoidal connections between the lumens of the primitive tubular heart in the early embryologic period. It is reported in 0.1%–0.2% of all cases of selective coronary angiography[1]. Most fistulae originate from the right coronary artery (60%) and terminate in the right side of the heart such the right ventricle or atrium, coronary sinus, and pulmonary vasculature. Most often congenital, a CAVF may rarely arise as a consequence of surgical complication, endomyocardial biopsy, invasive procedures[2, 3] or penetrating trauma. It could cause myocardial stealing due to run-off from the coronary vasculature to a low-pressure receiving cavity. Coronary artery that feeds the fistula progressively dilates, leading to complications of frank aneurysmal formation and mural thrombosis. Hence, all CAVF ought to be closed except for trivial ones. The evolution of 1st degree AV block in our case may reflect a flow limitation to atrioventricular (AV) node directly caused by the CAVF. CT angiogram has now emerged as an excellent imaging technique to delineate the lesion anatomy[4-6] CAVF generally requires closure. Transcatheter embolization techniques using coils, bags, or other devices can be performed successfully and safely, and are now the treatment modality of choice [7]. CAVFs with multiple connections, circuitous routes, and acute angulations may however be better treated surgically. Figure 1. Transthoracic echocardiogram performed showed the tubular structure coming off the right coronary cusp (bold arrow, image A); saccular formations adjacent to the aortic root in short axis and apical 4 chamber view (bold arrows, image B and C); as well as predominantly diastolic turbulent flow within the saccular formations (image D). Figure 2. Cardiac multidetector computed tomography (MDCT) angiogram volume rendering reconstruction of cardiac structures (images A-B) and multiplanar reconstruction images (images C-D) showed a dilated, tortuous right coronary artery (RCA) that eventually gave off a fistulous connection into the right atrium (RA).

I can hear it, but where is it coming from? A case of iatrogenic arteriovenous fistula after pacemaker lead extraction

A 54-year-old woman was referred to our institution for the assessment of a loud continuous murmur detected 3 years after pacemaker lead extraction. She previously had a dual-chamber pacemaker implanted for symptomatic sinus node dysfunction. Owing to recurrent and severe symptomatic phrenic nerve pacing, she underwent laser lead extraction. The procedure was complicated by a tear at junction of the superior vena …

Transcatheter Closure of Giant Ruptured Sinus of Valsalva Aneurysm

A 41-year-old woman presented with paroxysmal chest pain, dyspnea, and palpitations, and a continuous heart murmur was heard over the right upper and lower sternal borders. Transthoracic echocardiography revealed a giant ruptured sinus of Valsalva aneurysm (SOVA), which had dislodged and ruptured into the right atrium adjacent to the tricuspid valve. The diameter of the aortic end of the defect was 4 mm. Interestingly, this windsock SOVA swung into the right atrium and the right ventricle during different phases of the cardiac cycle (Figure 1 and Movie I in the online-only Data Supplement). Biatrial enlargement showed that the left atrial volume was 54 mL and the right atrial volume was 91 mL. We attempted to perform a transcatheter closure of this ruptured giant SOVA at the aortic end of the rupture site. Figure 1. A , Transthoracic echocardiogram obtained in the aortic short-axis view showing a giant windsock sinus of Valsalva aneurysm (SOVA), which had become dislodged and ruptured into the right atrium. It was adjacent to the tricuspid valve during systole. B , The SOVA swung into the right ventricle during diastole. …

Optical Coherence Tomography Findings in an Acquired Coronary Fistula

Most coronary artery fistulas (CAFs) have a congenital origin. Acquired CAF is a rare entity that may occur without an identifiable causative link. We present here the case of an acquired CAF in which optical coherence tomography was instrumental in outlining that its possible cause was a spontaneously ruptured, communicating, subadventitial coronary hematoma. A man aged 67 years was admitted for oppressive chest pain and sudden-onset dyspnea. He was a former smoker, had dyslipidemia and diabetes mellitus, and was in permanent atrial fibrillation. He also had had 2 mechanical valves implanted in the mitral and aortic positions in 1993 and 2003, respectively. No intervention in the tricuspid valve was performed. Before the second surgery, a coronary angiography revealed normal anatomy and the absence of obstructive atherosclerosis (Figure 1). At admission, he was normotensive and had mild signs of systemic congestion. A continuous soft murmur on the left sternal border was also heard. The ECG showed atrial fibrillation and a previously known complete left bundle-branch block with secondary ST-T changes. Transthoracic echocardiography showed normal function of both valves and of the left ventricle. Finally, the international normalized ratio was 4.0, and serial cardiac marker assays uncovered a rise in troponin I (peak, 5.29 U). Thus, myocardial infarction in the presence of a left bundle-branch block was diagnosed, and coronary angiography was scheduled. This …

Aorta-right atrial tunnel

Aorta-right atrial tunnel (ARAT), first reported in 1980 by Coto, is a rare congenital vascular anomaly. A 36-year-old female was admitted with chest discomfort, dyspnoea, palpitations, and general weakness. She had been treated for rheumatic fever at the age of 10, with no sequelae. Physical exam was normal except a grade 3/6 continuous murmur at the right sternal border. Transthoracic echocardiography (TTE) showed a tunnel-like shape …

Coronary aneurysm mimicking a five chamber heart

A 47-year-old soccer trainer was referred for a precordial murmur incidentally noted on routine physical examination. Cardiac auscultation revealed a grade 4/6 continuous murmur heard best on the left sternal border. No other sign was detected on physical examination. Chest X-ray and ECG showed no abnormalities. Transthoracic echocardiography …

An adult patient with patent ductus arteriosus: multimodality diagnostic approach

A 20 year-old man was admitted to the hospital with exertional dyspnoea (NYHA class II). Auscultation of his chest revealed a harsh, grade 3/6 continuous murmur which was loudest at the second left intercostal space; there were no signs suggestive of volume overload, ventricular failure, or raised pulmonary pressures. Chest X-ray demonstrated mild cardiomegaly with normal pulmonary vasculature, and electrocardiogram revealed normal sinus rhythm with no features of ventricular strain or atrial enlargement. Transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical Systems, Bothell, WA, USA) revealed a mean left ventricular ejection fraction of 60%. Left heart chambers and pulmonary artery were dilated. Initial TTE showed the presence of a large (1.65 cm2) window-like patent ductus arteriosus (PDA) in the suprasternal notch view. Colour floor M-mode echocardiography demonstrated a continuous left to right shunting from the aorta into the left pulmonary artery (Figs. 1A, B). Two-dimensional (2D) transoesophageal echocardiography (TEE) revealed a large window-like PDA (Figs. 1C, D). A subsequent real-time 3D TEE (3D RT TEE) revealed the presence of a large PDA (1.65 cm2) (Figs. 1E, 2A–D). Contrast enhanced thorax computed tomography (CT) demonstrated a large PDA with no additional cardiac abnormality (Figs. 3A, B). Ambulatory Holter recordings were normal. The patient was referred to cardiac surgery.

Aorta–to–Pulmonary Vein Fistula in an Asymptomatic 25-Year-Old Man

A 25-year-old man with no significant medical history was found to have a continuous murmur along the left sternal border on routine physical examination performed in preparation for running a marathon. Echocardiography showed a dilated left ventricle with normal function and continuous high-velocity flow in an aberrant vessel in close vicinity to the abdominal aorta (Movie I in the online-only Data Supplement). Chest x-ray (posterior-anterior and lateral projections, Figure 1) disclosed conglomeration of tubular densities in a scimitar pattern in the right lower lobe suggestive of anomalous pulmonary venous return of right lower lobe (scimitar syndrome; anomalous drainage of right lung pulmonary veins into the inferior vena cava). Cardiac magnetic resonance imaging (MRI) not only demonstrated normal drainage of all 4 pulmonary veins into the left atrium but also revealed an aberrant vessel (Movie II in the online-only Data Supplement) extending between the abdominal aorta and the right inferior pulmonary vein with an elevated systemic-to-pulmonary flow ratio of 1.8, consistent with a large left-to-left shunt. Cardiac computed tomography (CT) confirmed the presence of a large fistulous connection between the abdominal aorta and the right inferior …

A rare case of crossed pulmonary arteries in an infant - case report

Crossed pulmonary arteries are a quite rare form of pulmonary arterial malposition. In this anomaly, the left pulmonary artery originates from the pulmonary trunk to the right and usually above the origin of the right pulmonary artery. Both pulmonary arteries cross each other on their course to each respective lung. We presented a case of a Chinese infant with crossed pulmonary arteries. Physical examination showed a mild cyanosis and continuous machine-like heart murmur in the 2 intercostal space at the left sternal border. An echocardiogram revealed pulmonary hypertension, atrial septal defect, patent ductus arteriosus and ostial stenosis in the inferior left pulmonary vein. Dual-source CT angiography was performed for further evaluation of pulmonary trunk and its branches. Dual-source CT angiography showed origin of left pulmonary artery from the pulmonary trunk in a plane superior to that of the right pulmonary artery. The branch pulmonary arteries then crisscrossed as they coursed to their respective lungs. In summary, we report an infant with crossed pulmonary arteries who was diagnosed during dual-source CT angiography. Three-dimensional reconstruction is useful for visualizing this condition. Knowledge of this rare anomaly will help in the differential diagnosis of pulmonary artery abnormalities.

Continuous Heart Murmur-Two Cases of Rare Causes and Role of Imaging in Diagnosis

A continuous murmur is defined as a murmur that begins in systole, continues through the second heart sound and into part or all of diastole. Among a number of differential diagnoses, anomalous systemic arterial supply to the normal basal segments and Rupture of Sinus of Valsalva (RSOV) are two rare causes of continuous heart. These two entities, which are often overlooked clinically, may have potentially fatal complications. We herein present two cases of uncommon causes of continuous heart murmur; demonstrate the radiological features and corroborate the role of Electric Cardiogram-Gated Computed Tomography (ECG-gated CT) in diagnosis.

Duża przetoka wieńcowa i drożny przewód tętniczy – przezcewnikowe zamknięcie trzema nitinolowymi korkami przeznaczonymi do zamykania drożnego przewodu tętniczego

Coronary artery fistulas (CAF) are the most common congenital anomaly of this vessel. We present the case of a 26-year-old man with two coexisting congenital cardiac defects: patent ductus arteriosus (PDA) and CAF. The patient 3 months earlier had the transcatheter PDA closed (type A, diameter 4 mm) with a 10/8 mm PDA nitinol wire mesh occluder. After the procedure he continued to have symptoms of fatigue and continuous murmur in the precordial region persisted. In angio-CT a large coronary fistula from the circumflex coronary artery with suspicion of multiple orifices to the right atrium was found. An arteriovenous wire loop was created (guidewire introduced from the aorta through the CAF was snared using a lasso catheter in the superior vena cava and exteriorized through the right femoral vein). Retrogradely an 8 F long sheath and delivery system was introduced to the end of the fistula and a 12/10 mm Cardio-O-Fix PDA occluder (Starway Comp, China, Beijing) was implanted, closing one orifice of the CAF. Another leak (orifice of CAF – 3.5 mm diameter) was closed using a similar technique with a 10/8 mm PDA Cardio-O-Fix device. Complete closure of the coronary artery fistula and disappearance of the heart murmur were observed after the procedure. The patient was discharged home 4 days later on acetylsalicylic acid 150 mg/day. During 6 months of follow-up he was doing well without any complaints or pathological symptoms. In control angio-CT performed 3 months after the procedure complete closure of the CAF was confirmed.

Severely ectatic left circumflex coronary artery with fistula to coronary sinus presenting with acute coronary syndrome

Introduction: coronary artery fistulas are uncommon anomalies. they occur in 0.1–0.8% of patients undergoing coronary arteriography. the circumflex coronary arteriovenous fistulae (cAF) associated with aneurysmal dilatation and drainage into coronary sinus (cs) are even less common. We present a case of a 56-yearold male with an acute coronary syndrome who was found to have a tortuous and aneurysmal circumflex coronary artery terminating into the cs. case report: A previously healthy 56-yearold male developed acute retrosternal chest pain while skiing. Physical examination revealed a grade II/VI continuous murmur at the left lower sternal border, but was otherwise unremarkable. Laboratory investigations revealed an elevated troponin and st depression in the inferior leads on his electrocardiography. coronary angiography showed a diffusely aneurysmal circumflex artery with a fistula to the cs. the patient underwent successful surgical ligation of the fistula. conclusion: Our patient presented with an acute coronary syndrome caused by an uncommon form of coronary artery fistula. conventional coronary angiography failed to fully define the anatomy of the fistula (origin, pathway, and outflow). Multidetector computed tomography was complementary to demonstrate the complex anatomy of the fistula. the fistula was surgically ligated and he remains well.

Patent Ductus Arteriosus with Pulmonary Endarteritis

We herein report the case of a normal 63-year-old woman whose initial clinical symptom was a continuous fever above 38 degrees Celsius. Upon admission, a physical examination revealed a continuous heart murmur that was audible at the 2nd intercostals space along the left sternal border. Chest computed tomography revealed that vegetation was attached to the pulmonary arterial wall near the orifice of the duct (Picture 1, 2). Transesophageal echocardiography showed a continuous jet from the aortic arch to the pulmonary artery (Picture 3). She was therefore diagnosed with infective endocarditis due to patent ductus arteriosus. Her blood cultures revealed the presence of Pseudomonas aeruginosa. Surgical management was necessary due to the uncontrollable infection. A mattress suture was placed quickly in order to close the shunt flow via the pulmonary artery. The patient was transferred to the cardiology department at 13 days postoperatively in satisfactory condition without any critical complications. There have thus far been few reports concerning pulmonary endarteritis associated with silent patent ductus arteriosus (1, 2).