Diastolic Rumble Research Articles

Combined percutaneous balloonvalvuloplasty of mitral and tricuspid valves

Combined mitral and t r icuspid stenosis are rarely encountered in pat ients with rheumat ic hear t disease. 1 In spite of being a recently introduced technique, balloon valvuloplasty in noncalcified mitral stenosis has been found to be consistently effective in the t rea tment of this condition. 2 Successful double balloon valvuloplasty in t r icuspid stenosis 3, 4 has recently been reported. We repor t a case in which balloon valvuloplasty was performed on both the mitral and tr icuspid valves during the same procedure, with good immediate and midte rm results, A 48-year-old woman pat ien t with New York Hear t Association (NYHA) functional class I I I was admi t t ed to the hospital for the evaluation of rheumatic mitral and tr icuspid stenosis. Physical examinat ion showed a typical mitral facies with p inkish-purple patches on the cheeks, elevated jugular venous pressure, and mild hepatomegaly. A loud first hear t sound and an opening snap were heard at the apex, with a low-pitched diastolic murmur. There was also a diastolic rumble along the lower left sternal border combined with a systolic murmur , both increasing on inspiration. The electrocardiogram (ECG) showed atr ial fibrillat ion and right-axis deviation. The chest x-ray film showed left and right atr ial enlargement with increased upper lobe vascular markings and enlargement of the pulmonary arteries. Echo-Doppler technique showed pure mi t ra l stenosis. The valve was flexible, with no evidence of calcification. Mit ra t valve area, calculated from the mitral flow using the pressure halft ime method as described by Hatle et al., 5 was 1 cm 2. Direct p lanimetry of the mitral orifice gave a valve area of 1.1 cm. 2 The left a t r ium was moderately enlarged and the left ventricle was normal. The tr icuspid valve showed a combinat ion of stenosis and mild incompetence. Tricuspid pressure halft ime was 366 msec. In the light of these findings, we decided to a t t empt percutaneous balloon valvuloplasty on both valves if the assessment was corroborated by diagnostic catheterization. Wri t ten consent was obtained from the pat ient . The catheterizat ion included the measurement of the mitral valve gradient, cardiac outpu t ( thermodilution), and calculation of the area using Gorlin's formula. A left ventriculogram was performed in the right anterior oblique view. Simultaneous recordings of

Percutaneous Transvenous Mitral Commisurotomy in a Patient with Severe Mitral Stenosis Associated with Circulating Blood Lupus Anticoagulant

A forty-six year old female with severe mitral valve stenosis complicated by thrombocytopenia and a positive test for lupus anticoagulant was reported. Ten years ago, she was diagnosed to have thrombocytopenia when she received a mastectomy. She had a history of total of 6 spontaneous abortions, but no history of thromboembolic episodes. She received a steroid hormone therapy for thrombocytopenia for 5 years, but thrombocyte count did't show an increase. A year ago, she suffered from a congestive heart failure. At a local hospital, digitalis and a diuretics were given to her, but her condition remained unimproved.She was referred to our hospital. On phisical examination, a diastolic rumble and an opening snap were audible at the apex of the heart. A hepatosplenomegaly was noted. Laboratory tests revealed a thrombocytopenia with the count of 58, 000/mm3, and the prolongation of APTT as well as bleeding time. Radioisotopic examination employing111 In revealed a platelet life span of 4.6 days. A serum β-TG and a serum PF-4 levels were markedly increased.The serum anticardiolipin antibody titre level was significantly high. The serum mixing test between the sera from this patient and the sera from healthy persons showed a marked prolongation of APTT.A cardiac catheterization revealed severe mitral valve stenosis with a transvalvular pressure gradient of 25.2mmHg, and a pulmonary arterial pressure of 68/32mmHg. Since the risk for an open-heart surgery was too high in a patient with coagulopathy and thrombocytopenia, the treatment of choice seemed to be a percutaneous transvenous mitral commissurotomy (PTMC). In our case, the transmitral pressure gradient dropped from 25.2 to 12.9mmHg after PTMC. She was able to go back to her daily life.

Phonoechocardiography and intracardiac phonocardiography in hypertrophic cardiomyopathy.

The salient phonoechocardiographic features of patients having hypertrophic cardiomyopathy (HCM) with or without left ventricular outflow tract (LVOT) gradients are reviewed. Intracardiac sound and pressure recordings from high fidelity catheter-tipped micromanometers have documented that the precordial murmur is the summation of both the systolic ejection murmur (SEM) arising from the LVOT, as well as the mitral regurgitant murmur recorded from the left atrium. The intensity of the precordial murmur varies directly with the LVOT gradient, which in turn is determined primarily by the contractility and loading conditions of the left ventricle. Reversed splitting of the second heart sound (S2) with paradoxical respiratory movement is a common finding in HCM, and when present, almost always denotes a significant LVOT gradient. It is due to marked lengthening of the left ventricular ejection time secondary to prolongation of the contraction and relaxation phases of left ventricular systole. The presence of a fourth heart sound (S4) is the rule in HCM when normal sinus rhythm is present, and is a reflection of a forceful left atrial contraction into a hypertrophied noncompliant left ventricle. A third heart sound (S3) is also common in HCM, and often the initial vibrations occur before the 0 point of the apexcardiogram (ACG) and continue giving the auscultatory impression of a diastolic rumble. When associated with a loud S1, which is frequently present, the clinical presentation may mimic mitral stenosis. This is particularly true when the patient has chronic atrial fibrillation. Careful attention to evidence of marked left ventricular hypertrophy as well as the typical echocardiographic findings of HCM preclude this diagnosis. In conclusion, phonoechocardiography is a simple non-invasive technique which almost always makes the definitive diagnosis of HCM.

“Mitral stenosis” secondary to combined “massive” mitral anular calcific deposits and small, hypertrophied left ventricles: Hemodynamic documentation in four patients

Certain observations are described in four elderly women with massive mitral anular calcific deposits, small thick-walled left ventricles and diastolic gradients between pulmonary artery wedge position (or left atrium) and left ventricle. All four patients had some degree of obstruction to left ventricular outflow. Examination at necropsy (two patients) or at operation (one patient) disclosed only focal fibrous thickening of the mitral leaflets without commissural or chordal fusion. By auscultation, none had mitral opening snaps, only two had loud first heart sounds and only one had a mitral diastolic rumble. Hemodynamic documentation of a diastolic gradient between pulmonary artery wedge position (or left atrium) and left ventricle in the presence of massive mitral anular calcific deposits and in the absence of diffuse disease of the mitral leaflets has not been demonstrated previously. The diastolic gradients are considered to result from the combination of the large mitral anular calcific deposits and the small, thick-walled, noncompliant left ventricles.

Diastolic Rumbles in Normally Functioning Porcine Mitral Valves

Fourteen of 22 patients (64%) with normally functioning porcine prosthetic valves in the mitral position had apical diastolic rumbles on phonocardiogram and by auscultation. Six (27%) had opening snaps. Factors necessary for the production of a diastolic rumble appear to include central flow, a flexible stent, and the presence of biologic material. Clinicians should be aware that diastolic murmurs and snaps occur in the normally functioning porcine valve.

Late Mitral Valve Opening in Aortic Regurgitation

Austin Flint first described the occurrence of an apical diastolic rumble in patients with severe aortic regurgitation. 1 Flint A On cardiac murmurs. Am J Med Sci. 1886; 91: 27 Crossref Google Scholar With the advent of echocardiography, mid and late mitral valve closure have been demonstrated in some patients with this murmur. 2 Fortuin NJ Craige EP On the mechanism of the Austin Flint murmur. Circulation. 1972; 45: 558 Crossref PubMed Scopus (48) Google Scholar , 3 DeMaria AN King JF Salel AF et al. Echography and phonography of acute aortic regurgitation in bacterial endocarditis. Ann Intern Med. 1975; 82: 329-335 Crossref PubMed Google Scholar The reverse situation, early mitral valve closure with late mitral valve opening, has been described less frequently.

Surgical indications and results for congenital cardiac anomalies associated with left to right shunt and severe pulmonary hypertension.

Prior to 1970, 35 patients of VSD with Pp/Ps of 0.8 or more were subjected to primary closure of the defect, resulting in 11 operative deaths. Since 1971, however, the surgical results have been much improved and 29 such patients were operated on without death. It has been considered the optimal time of elective closure of VSD with severe pulmonary hypertension is at the age of 1 to 3 years, however, if decrease in apical diastolic rumble and heart size are found, earlier operation less than one year of age is to be scheduled. Surgical indications and results of PDA, PDA with VSD, and ASD associated with severe pulmonary hypertension were also discussed.

Doppler echocardiography. The localization of cardiac murmurs.

A range-gated pulsed Doppler flowmeter has recently been developed that measures the average velocity of blood flow within a small tear-drop shaped (4 mm by 2 mm) sample volume. Unlike the continuous wave Doppler, the distance from the transducer face to the sampling site can be continuously varied by a range adjustment knob. Twenty patients with cardiac murmurs were evaluated in a noninvasive laboratory by brief cardiac physical examination, abbreviated phonocardiogram, complete echocardiogram, and localization of the murmurs by Doppler echocardiography. The localization depends on the detection of turbulent flow or jets at the sampling site. The murmurs included the diastolic rumble of mitral stenosis, mitral regurgitation, the murmur of left ventricular outflow tract obstruction, aortic stenosis, aortic insufficiency, diastolic rumble of tricuspid stenosis, augmented right ventricular filling sound in atrial septal defects, pulmonic stenosis, pulmonic insufficiency, and high velocity flow through the obstruction in ccarctation of the aorta.

Hemodynamic and phonocardiographic correlates of the Austin Fint murmur

Hemodynamic studies in 12 patients with isolated severe aortic regurgitation, and an apical diastolic rumble (Austin Flint murmur) showed a characteristic pressure tracing in diastole. Simultaneously recorded direct or indirect left atrial and left ventricular pressures showed that left atrial pressure was significantly higher than left ventricular pressure in early diastole and that at end diastole, the ventricular pressure was higher than atrial pressure. This pressure phenomenon was not observed in five patients with equally severe aortic regurgitation who did not have an apical diastolic rumble. The left ventricular end diastolic pressure was markedly elevated in all 12 patients with the Austin Flint rumble. The possible relationship of these hemodynamic findings to the genesis of the Austin Flint murmur is discussed.

Early stage of tricuspid stenosis

Twelve patients are presented with rheumatic valve lesions and a typical tricuspid diastolic rumble presenting inspiratory accentuation. All the patients, except one, were in sinus rhythm. No tricuspid diastolic gradient was found when they were first catheterized. An intracardiac diastolic rumble with inspiratory accentuation was recorded in the right atrium or ventricle, or both. Five of the patients were recatheterized after an interval of 1 to 3 years, and, although the clinical picture was unchanged, small tricuspid gradients were recorded. A diminution of cardiac output and an increase of right atrial mean pressure were also observed. It should be accepted that, at an early stage of tricuspid stenosis, a tricuspid gradient may be absent while the auscultatory and phonocardiographic signs may be the only indication of the tricuspid lesion.

Opening snap in relative tricuspid stenosis: Report of two cases of atrial septal defect ∗

The auscultatory and phonocardiographic findings in 2 cases of atrial septal defect are presented. The diagnosis of the disease was confirmed by cardiac catheterization. A large left to right shunt was present in both cases. In addition to the usual auscultatory and phonocardiographic findings of atrial septal defect, an opening snap of high frequency was clearly audible and registered at the xiphoid, the left lower sternal border and to the right of the sternum. This opening snap is attributed to the sudden billowing of the tricuspid leaflets caused by increased flow across the valve. At the same time a diastolic rumble was present in the same area, and the first sound was loud and split. The presence of an opening snap, in addition to the other auscultatory and graphic findings, can be a source of diagnostic error in cases of atrial septal defect.

Early transient mid-diastolic murmur in rheumatic fever

An apical diastolic rumble often appears during the first episode of active rheumatic fever within the first week of the illness. It is associated with an abnormal apical systolic murmur due to mitral regurgitation. Since mitral stenosis takes months or years to develop, such a diastolic murmur should not be regarded as being due to mitral stenosis. Various theories were advanced about the origin of the murmur. We have explained it as being due to dilatation of the left ventricle. The disappearance of the murmur within a few weeks coincides with the improvement of the patient's condition, and with the disappearance of the other clinical and laboratory signs of rheumatic activity. The phonocardiographic tracings of two cases demonstrate the mid-diastolic murmur, which appeared early in the disease and subsequently disappeared.

Evolution of murmurs in early rheumatic heart disease

A clinical and phonocardiographic study was made in forty-three patients at the first attack of rheumatic fever and was repeated until either recovery or a definite chronic course was evident. The patients were divided into four groups: (1) Those who had only systolic murmurs at the first observation. This group included twenty cases; murmurs were present at the apex, pulmonic and aortic areas for the most part. The murmurs decreased or disappeared in about one-half of the cases; they increased in the other half. About one-third of the basal systolic murmurs were proved to be transmitted, while two-thirds were of aortic or pulmonic origin. A significant pulmonic systolic murmur was present in one-half of the cases at the beginning, in about one-fourth at the end. A significant aortic systolic murmur was present in one-fifth of the cases both at the beginning and at the end. (2) Those who had both a systolic murmur and a diastolic rumble at the apex at the first observation. These were all severe cases. At the end of the period of observation nearly two-thirds of the patients showed no further evidence of the diastolic rumble. (3) Those who had an apical systolic and an aortic diastolic murmur at the first observation. The aortic diastolic murmur subsequently decreased in one case; it persisted or increased in the others. (4) Those with minimal, diffuse murmurs. Among other points discussed are: (1) the advantage of using phonocardiographic documentation for the study of rheumatic patients, (2) the frequency of triple rhythm, and the pathogenetic mechanisms involved; (3) the mechanism of production of the various murmurs, and the possibility of distinguishing a diastolic rumble due to “relative” stenosis from one caused by organic mitral stenosis.

PROBLEM OF DIFFERENTIAL DIAGNOSIS IN INFANTS WITH LARGE HEARTS AND INCREASED BLOOD FLOW TO THE LUNGS

This paper deals with the differential diagnosis of the cardiac lesion in infants who have enlargement of the heart associated with increased blood flow to the lungs, and in whom cyanosis is not a prominent feature. Some patients in this group have a patent ductus arteriosus in the absence of a typical continuous murmur, and these infants may urgently require the benefits of surgical therapy. Since the diagnosis can be established by aortography or heart catheterization, some criteria are required for the better selection of infants from this group in whom these investigations should be performed. Twenty-five infants form the subject of this study. In 19 the diagnosis was confirmed at autopsy. Eight patients had a patent ductus, either as an isolated lesion or in association with other defects; 10 had ventricular septal defects with or without overriding of the aorta; 5 had anomalous pulmonary vein drainage; one had an ostium atrioventricular communis and in one there was a functional single ventricle. Clinical, electrocardiographic and radiologic findings were analyzed. Important features which appear to favour the diagnosis of patent ductus arteriosus are full or collapsing pulses and a normal ECG or one showing evidence of combined ventricular hypertrophy. Suggestive, but of lesser importance, is the finding of an apical diastolic rumble and enlargement of the left atrium. All these findings may, however, be present in patients with other malformations, especially defects involving the ventricular septum. Evidence of marked hypertrophy of the right atrium and right ventricle by electrocardiography and fluoroscopy renders the presence of patent ductus unlikely and is consistent with the diagnosis of anomalous drainage of pulmonary veins.

On the apical sounds and murmurs in aortic regurgitation

1. 1. A phonocardiographic study was made on twenty-seven patients with syphilitic aortic regurgitation in order to study the auscultatory phenomena at the apex. 2. 2. Some of the patients showed one of the following acoustic phenomena: 2.1. a. The presence of additional sounds during diastole (third sound. auricular sound, or both). 2.2. b. The presence of a “crescendo” type of first sound. 2.3. c. The presence of a split first sound, due either to increased loudness of the two valvular components or to increased loudness of the vascular component. The above-mentioned phenomena may simulate, to the ear, either a diastolic rumble or a presystolic murmur. They were easily recognized on phonocardiographic tracings, so that mitral stenosis was excluded after study of the tracings.