Intracardiac Phonocardiography Research Articles

Determination of site of infection in endocarditis.

Medical-surgical treatment of antibiotic refractory endocarditis requires determination of the site of infection, which is not always possible with conventional cardiac catheterization. The cases of two patients with right-sided endocarditis who survived after combined medical-surgical therapy are presented. One had persistent Pseudomonas aeruginosa bacteremia and three possible sites of infection. Multiple quantitative blood cultures proximal and distal to each suspected site indicated the pulmonary valve alone was infected. The second had sustained bacteremia with three enteric organisms and no apparent valvular abnormality. Quantitative cultures excluded the abdomen as the continuing source of bacteremia and suggested the tricuspid valve was infected. This was confirmed by a second catheterization using multiple cultures in conjuction with dye dilution studies, intracardiac phonocardiography, and angiography. These bacteriologic and cardiologic techniques may be especially useful in detecting right-sided endocarditis and may also be helpful in detecting concomitant infection of both sides of the heart.

Nonobstructive hypertrophic cardiomyopathy mimicking mitral stenosis: Documentation by echocardiography, phonocardiography and intracardiac pressure and sound recordings

The physical findings in hypertrophic cardiomyopathy with left ventricular outflow tract obstruction are well described. In the absence of outflow tract obstruction the findings are less distinctive. There have been several reported cases in which the cardiac findings have suggested the diagnosis of mitral stenosis. In this report we describe a patient whose auscultatory and roentgenographic findings more closely mimicked mitral stenosis. The patient had a loud first heart sound, mitral opening snap and an apical presystolic murmur; left atrial enlargement was present. Noninvasive studies, including phonocardiography, echocardiography and apex cardiography, strongly suggested the correct diagnosis of nonobstructive hypertrophic cardiomyopathy. The diagnosis and unusual auscultatory findings were confirmed by results of cardiac catheterization and intracardiac phonocardiography. The importance of recognizing this syndrome and the use of noninvasive methods to establish the diagnosis are stressed.

Spurious tricuspid regurgitation. Three conditions mimicking tricuspid regurgitation diagnosed at operation.

<b>Brown, A. H., and Braimbridge, M. V. (1973).</b><i>Thorax</i>, <b>28</b>, 495-497. <b>Spurious tricuspid regurgitation: Three conditions mimicking tricuspid regurgitation diagnosed at operation.</b> The diagnosis of tricuspid incompetence is difficult. Three patients are described in whom the diagnosis of tricuspid regurgitation was made but disproved by the findings at surgery. The first patient had aortic regurgitation, mitral regurgitation from chordal rupture, and constrictive pericarditis; the right atrium was compressed between the pulsating left atrium and the tight pericardium. The chordal rupture caused the mitral murmur to radiate parasternally. The second patient had severe mitral and aortic regurgitation and an interatrial septal defect with transmission of the left-sided `v9 waves to the right atrium. The third patient had an iatrogenic Gerbode defect from a previously repaired ostium primum atrial septal defect. Intracardiac phonocardiography failed to distinguish the anatomical situation from tricuspid regurgitation. The best assessment of tricuspid valvular disease is still that of the surgeon at operation.

Coronary arteriovenous fistula complicating aortocoronary bypass surgery

A coronary artery fistula complicating aortocoronary bypass surgery is reported in a patient. A continuous murmur heard on follow-up visits was the important clinical clue. The diastolic murmur was localized by intracardiac phonocardiography to the area of the tricuspid valve. A small left-to-right shunt was demonstrated in the right ventricle. Angiographic studies demonstrated a saccular structure arising from the left anterior descending artery, just distal to the anastomotic site and communicating with the right ventricle through a maze of vessels.

Right-sided austin flint murmur: Documentation by intracardiac phonocardiography, echocardiography and postmortem findings

A 25 year old man with multiple congenital cardiac defects, pulmonary hypertension, pulmonary reguritation had a loud mid-diastolic rumbling murmur with presystolic accentuation, heard best at the lower left sternal border and cardiac apex. Intracardiac and external phonocardiograms, echocardiograms and postmortem findings documented that the rumble represented a “right-sided Austin Flint” murmur.

Continuous murmurs associated with shunts in the acyanotic adult: An anatomic classification

A continuous murmur may be precisely localized within a cardiac chamber or great vessel with intracardiac sound-pressure sensitive devices. Intracardiac sound studies were performed in eighteen acyanotic adults who had continuous murmurs associated with shunts. The continuous murmur was localized to the site at which the fistula or communication terminated or emptied in fifteen patients. This information has been translated to the precordial auscultatory areas (designated on the basis of sound or murmur localization by intracardiac phonocardiography) and forms the basis for an anatomic classification for continuous murmurs associated with shunts in acyanotic adults.

Congenital pulmonary valvular insufficiency complicating tetralogy of fallot: Intracardiac sound and pressure correlates

A case of tetralogy of Fallot with organic pulmonic insufficiency is presented with confirmation by cardiac catheterization with angiocardiography and simultaneous intracardiac phonocardiography and pressure measurements. Simultaneous intracardiac sound and pressure correlates proved valuable in elucidating the mechanism for the production of the unusual murmur of organic pulmonic insufficiency. The murmur occurs simultaneously with the low diastolic pressure gradient between the pulmonary artery and the right ventricle during low velocity regurgitation, and is delayed in onset following aortic closure. The silent interval in this study represents the period during isometric relaxation of the hemodynamically functioning “single” ventricle and during early diastole when the respective systolic and diastolic gradients are insufficient to generate audible sound. This case occupies a unique position in the spectrum of pulmonic insufficiency, with hypertensive pulmonic insufficiency and the Graham Steell murmur at one end, and nonhypertensive, isolated congenital pulmonic valvular insufficiency at the other end.

Precordial-intracardiac phonocardiographic correlative study of ventricular septal defect.

Precordial and intracardiac phonocardiographic correlation was investigated in 28 cases with ventricular septal defect (VSD) to confirm the diagnostic value of intracardiac phonocardiography and to clarify the clinical as well as physiological significance of the point of maximum intensity (PMI) of the regurgitant systolic murmur of VSD. At the same time, the teleological use of catheterization was documented and the recent concept of the auscultatory was modified.(1) The regurgitant systolic murmur of VSD was localized within the right ventricle (RV) or partially transmitted toward the pulmonary artery (PA) and had the PMI somewhere in the RV. The murmur was pansystolic in timing and had a wide frequency span. A few exceptional cases were described, but the murmur of these cases became typical following the administration of methoxamine. The findings due to the associated anomalies were documented. The fact that the presence of regurgitant systolic murmur within the RV is the most sensitive diagnostic clue of VSD was confirmed.(2) The PMI of the regurgitant systolic murmur within the RV was so localized that it was easy to locate the site of the septal defect in almost all cases.(3) The localized PMI within the RV was the best site for the sampling of any measurements. The oxygen content was significantly high at this point when compared to those of randam sampling. This fact enables us to utilize teleologically the catheterization to detect the shunt. Methoxamine administration made the oxygenation of the sample conclusive in doubtful cases.(4) In a dorsoventral projection to the chest wall, intracardiac PMI of the regurgitant systolic murmur coincided with the precordial PMI in all cases. Therefore, the sampling at the site immediately beneath the precordial PMI was also recommended instead of the intracardiac PMI whenever the intracardiac phonocardiography was not available. Moreover, the site of septal defect could be anticipated in many cases with a reasonable accuracy based on this topographical correspondence of both PMIs.(5) The correspondence of the 2 (intracardiac and precordial) PMIs suggests that there is a direct transmission of the murmur from the origin to the chest wall. In this regard, the present authors made a minor modification to the revised auscultatory areas for the sake of the regurgitant systolic murmur of VSD and reserved a name of interventricular septal area to the precordial PMI.

Interatrial septalmurmurs i secundum type atrial septal defect. Intracardiac phonocardiographic and hemodynamic study.

Interatrial septal murmurs were investigated by means of intracardiac phonocardiography and hemodynamics.1) The murmur was detected in 77% of total 31 cases of secundum type ASD.2) The murmur was localized at the site of septal defect and usually not transmitted widely because of the low intensity. It was essentially continuous, starting from late systole and continuing to diastole, and lowto medium-pitched. The systolic component was dominant at the left side of the septum, whereas the diastolic accentuation was observed at the right side of it. Respiration influenced the intensity and it was usually louder in expiration. Methoxamine intensified the murmur.3) Hemodynamic study disclosed that the determinant was the interatrial (left-to-right atrial) pressure gradient mainly observed during the phase of v wave. Occasionally, pressure gradient of a waves was present with concomitant atrio-systolic murmur. The significance of the hemodynamic determinant was discussed.4) The audibility of the interatrial septal murmurs by precordial auscultation depends on several factors which are discussed in detail. Rare instance, in which the murmur appeared in the 3rd left interspace, was demonstrated, and discussion was made on the detection of the murmur and its topographic localization.5) Other diastolic murmurs, particularly that of relative tricuspid stenosis, were also investigated in order to differentiate from the interatrial septal murmurs.6) The clinical meaning of the interatrial septal murmurs was mentioned.

Pulmonary valvular insufficiency

Described herein are seven patients with pulmonary valvular regurgitation; in five it was the only cardiovascular defect. Four had isolated congenital pulmonary insufficiency; one had isolated pulmonary insufficiency following staphylococcal endocarditis; and two had pulmonary regurgitation in association with congenital pulmonary valvular stenosis. The diastolic murmur of isolated pulmonary valvular regurgitation is similar in location to that of aortic valvular insufficiency but can usually be distinguished from it. With isolated pulmonary valvular regurgitation, the diastolic murmur tends to be more delayed in onset, beginning with pulmonary closure rather than the earlier aortic closure. The murmur is usually of low pitch, has crescendo-decrescendo quality and often is increased during inspiration. The diagnosis of pulmonary valvular regurgitation can be confirmed by demonstration of a low diastolic pulmonary artery pressure at right heart catheterization, by pulmonary arteriography, by indicator-dilution methods and by intracardiac phonocardiography, which shows that the diastolic murmur is loudest in the outflow tract of the right ventricle. Aortography is useful to exclude aortic insufficiency as the cause of a diastolic murmur along the left sternal edge. Isolated pulmonary valvular insufficiency is usually compatible with many decades of normal life; hence, it is important to distinguish this disorder from aortic insufficiency. Since pulmonary valvular regurgitation more commonly accompanies other cardiovascular disease, especially pulmonary stenosis or pulmonary hypertension, its presence is an indication to search for other cardiovascular defects. The diseased pulmonary valve may be the seat of bacterial infection, and the existence of pulmonary valvular regurgitation is probably an indication for prophylactic measures against bacterial endocarditis.

Basal diastolic murmurs in rheumatic heart disease: Intracardiac phonocardiography and cineangiography

Basal diastolic murmurs in rheumatic heart disease: Intracardiac phonocardiography and cineangiography

Intracardiac phonocardiography in the diagnosis of small patent ductus arteriosus with atypical murmur.

Abstract The diagnosis of a small patent ductus arteriosus with minimal left‐to‐right shunt is made when the continuous murmur is recorded in the pulmonary artery by intracardiac phonocardiography during a simple right heart catheterization.The diagnosis was established in one patient, in whom the patent ductus was the only lesion, and in four patients with additional defects. In none of the patients was the typical continuous murmur present at external auscultation; two of the patients had only a systolic external murmur.

The interpretation of intracardiac phonocardiography of a continuous murmur developed after radical operation for tetralogy of Fallot.

A patient with tetralogy of Fallot developed a continuous flow-like murmur after radical operation. At right-heart catheterization with intracardiac phonocardio-graphy, the continuous murmur was recorded in the entire inflow tract of the right ventricle and was erroneously interpreted as being due to an arteriovenous fistula to the right ventricle. Thoracic aortography demonstrated aortic insufficiency and a residual ventricular septal defect with left-to-right shunt as the cause of the continuous murmur. The diagnostic value of intracardiac phonocardiography in such cases is based on the assumption that the diastolic component of aortic insufficiency is not recordable in the right ventricle; the reported case indicates that intracardiac phonocardiography may be of limited diagnostic value after radical operation for tetralogy of Fallot.

Quadrivalvular heart diseases. An autopsied case with massive pulmonary regurgitation.

An autopsied case of quadrivalvular heart disease was described, in which pulmonary regurgitation due to possible bicuspid valve was predominant and tricuspid stenosis, mitral stenosis, and aortic stenosis with insufficiency coexisted. The patient was 47, and finally 53 years old female with long-term history of cough due to bronchial compression by the enormously dilated pulmonary artery. Clinical examination revealed massive pulmonary regurgitation, which was further substantiated by right heart catheterization and cineangiocardiography. The phonocardiograms and the reference tracings suggested the co-existence of tricuspid stenosis, aortic stenosis with regurgitation and mitral stenosis. Cardiac catheterization, intracardiac phonocardiography and angiocardiography also favored to the diagnosis of organic tricuspid stenosis. However, the ignorance of the presence of such an unusual combination misled to the precise antemortem diagnosis.Discussion was made on the rarity of quadrivalvular heart disease, and the pathogenesis of this unusual pulmonary regurgitation was analyzed based on the autopsy finding and the history as well as the clinical manifestation. Finally, combination of the murmurs of organic and relative tricuspid stenosis was presented to explain the acoustical findings of the present case.

Intracardiac phonocardiography and hemodynamics in pure mitral insufficiency.

Intracardiac phonocardiography and hemodynamics in pure mitral insufficiency.

The ballooning mitral valve in patients with the “precordial honk” or “whoop”

Eight patients with a “precordial honk” or “systolic whoop” were studied by complete right and left heart catheterization and left ventricular cineangiocardiography. The patients were divided into two groups on the basis of the absence (group 1) or presence (group 2) of significant heart disease. In all 5 patients in group 1 and in 1 in group 2, ballooning of the mitral valve into the left atrium during ventricular systole was demonstrated on the cineangiograms. The ballooning mitral valve was associated with late systolic mitral insufficiency in 4 of the 5 patients in Group 1. The incidence of the ballooning mitral valve in this laboratory was determined from 200 consecutive left ventricular cineangiocardiograms obtained from patients with a variety of cardiac lesions. Twelve of these patients (6%) had a ballooning mitral valve, and 10 of these 12 had coexisting mitral insufficiency. The electrocardiographic features of patients with a “precordial honk” or “whoop” were discussed, and possible mechanisms for the genesis of the sound were suggested. That the “precordial honk” is intracardiac in origin has been demonstrated by several investigators using intracardiac phonocardiography. This report presents anatomic evidence for these data i.e., ballooning of the mitral valve and late systolic mitral insufficiency.

Intravascular Phonocardiography in Clinical and Experimental Peripheral Pulmonary Artery Stenosis

SUMMARY 1.Thirteen patients with pulmonary artery branch stenosis proved by angiography have been presented. 2.All patients, except one, had systolic murmurs audible throughout both lung fields. One patient had a continuous murmur radiating to the entire left lung field. 3.Intracardiac phonocardiography was done in 12 patients and systolic murmurs localized distal to the stenotic site were recorded. Similarity was found between murmurs recorded on the chest wall and within the stenotic vessel. 4.Main pulmonary artery pressure curves were thought to be strongly suggestive of the diagnosis in all the cases of bilateral or multiple peripheral pulmonic stenosis. 5.Simultaneous pressure and sound recordings have been used to study the mechanisms involved in the production of stenotic murmurs within the pulmonary vasculature in experimental preparations in dogs. Systolic and continuous murmurs were produced by graded constriction of one or both pulmonary artery primary branches. The timing and intensity of these murmurs were found to be a function of the magnitude and duration of the pressure gradient created across the stenotic sites.

Basal diastolic murmurs in rheumatic heart disease: Intracardiac phonocardiography and cineangiography

Basal diastolic murmurs in rheumatic heart disease: Intracardiac phonocardiography and cineangiography

Pulmonary valve regurgitation secondary to bacterial endocarditis in heroin addicts

Two cases of pulmonary valve regurgitation secondary to right-sided staphylococcal endocarditis in heroin addicts are oresented, and the characteristic features of the diastolic murmur are described. Intracardiac phonocardiography localizes the murmur at the pulmonary valve and is the simplest, most reliable method for documentation of the lesion.

The origin of the innocent "vibratory" murmur studied with intracardiac phonocardiography.

The origin of the innocent "vibratory" murmur studied with intracardiac phonocardiography.