Loud Continuous Murmur Research Articles

Ventricular septal defect associated with aortic regurgitation and ascending aortic aneurysm: a case report

IntroductionVentricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to prolapse of the aortic cusp.Case presentationWe present a case of 23-year-old White man with VSD, AR and ascending aortic aneurysm. The patient presented to outpatient clinic with weakness and gradual worsening shortness of breath for the past 5 years. Clinical examination revealed regular heart rhythm and loud continuous systolic-diastolic murmur (Lewin’s grade 6/6), heard all over the precordium, associated with a palpable thrill. The ECG showed right axis deviation, fractionated QRS in V1 and signs of biventricular hypertrophy. The chest X-ray showed cardiomegaly. Transthoracic and transesophageal echocardiograms showed a perimembranous VSD with moderate restrictive shunt (Qp/Qs = 1.6), aortic regurgitation (AR), and ascending aortic aneurysm. Other clinical and laboratory findings were within normal limits.ConclusionsPerimembranous VSD, may be associated with aortic regurgitation and ascending aortic aneurysm as secondary phenomenon if it is not early diagnosed and successfully treated.

Doubly Committed Subarterial Ventricular Septal Defect Coexisted with Ruptured Aneurysm of The Right Sinus Valsava

Sinus of Valsalva aneurysms (SVAs) are uncommon cardiac abnormalities and most of them are in congenital origin. Some patients may have SVAs that concomitant with ventricular septal defect (VSD). Here, we reported case of a 37-year-old male presented with worsening exertional dyspnoea. Thrills and loud continuous murmur along the left sternal border were discovered during physical examination. Echocardiogram displayed ruptured sinus of valsalva aneurysm to the right ventricle along with supracristal ventricular septal defect (VSD). The patient underwent surgical correction with patch repair and aortic valve replacement. Most cases of SVAs were originated from right coronary sinus. They usually ruptured into right ventricle. Ventricular septal defects often coexisted with this condition. Echocardiography provided a complete evaluation of such cases and prohibited missed diagnosis of other coexistent congenital heart defects.

Persisterende ductus arteriosus en pulmonalisstenose bij een labrador-retriever

Een drie maanden oude, vrouwelijke, intacte labrador-retriever werd doorverwezen wegens een vermoedelijk congenitaal hartprobleem. Klinische symptomen waren niet aanwezig, maar op het lichamelijk onderzoek werd een luide, continue hartruis met fremitus opgemerkt (graad 5 op 6) ter hoogte van de linkerhartbasis. Door middel van echocardiografie werd de diagnose van persisterende ductus arteriosus (PDA) en pulmonalisstenose (PS) gesteld. Anderhalve maand na de initiële presentatie werd de PDA chirurgisch gesloten. De PS werd medicamenteus behandeld met de ß-blokker atenolol en werd verder opgevolgd om de respons op deze therapie en de eventuele noodzaak van een ballonvalvuloplastie te evalueren. Deze casus toont aan dat een kwalitatief en volledig echocardiografisch onderzoek steeds noodzakelijk is bij een jong dier met een hartruis. Ook wanneer de oorzaak van de hartruis snel geïdentificeerd kan worden, in het voorliggende geval persisterende ductus arteriosus, moet er gecontroleerd worden op eventuele bijkomende afwijkingen, zoals hier pulmonalisstenose.

Ruptured sinus of valsalva aneurysm: Clinical case presentation and management

A 27-year-old female presented with generalized body swelling and progressive shortness of breath for the past 4 months. On examination, she had a loud continuous murmur, elevated jugular venous pressure, and gross ascites. The examination findings, electrocardiogram, chest radiography, and echocardiogram are discussed in a step-wise manner to arrive at a diagnosis and plan of management of a patient with ruptured sinus of Valsalva aneurysm is discussed along with review of relevant literature.

Self-assessment questions: paediatric cardiology

A 2-month-old baby with known hypoplastic left heart syndrome presents to the paediatric emergency department from home with a history of poor oral feeds and lethargy. The parents describe the baby having had profuse watery diarrhoea and non-bilious vomiting over the last 24 hours. Urine output has been reduced to about half the usual amount according to the family. The patient is on 12 hourly furosemide and spironolactone (each at 1 mg/kg/dose), 8 hourly captopril (0.3 mg/kg/dose) and aspirin (5 mg/kg/daily). On examination, the baby is clubbed and cyanosed with a sternotomy scar and a loud continuous murmur at the right upper sternal border radiating to the back. The anterior fontanel is slightly sunken. The abdomen is soft and non-tender with active but normal pitched bowel sounds.

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 …

A device-occluded ductus arteriosus rendered patent by acute dissection involving the main pulmonary artery and the descending aorta

A 72-year-old woman presented with severe central chest pain and a loud continuous murmur. Blood pressure was 105/70 mmHg. She had undergone elective aortic valve and root replacement 7 years previously. Her coronary angiogram was normal. Three years later, a patent ductus arteriosus (PDA) which had been missed was successfully closed percutaneously using …

Definitive diagnosis of ruptured sinus of Valsalva in a patient with ventricular septal defect using cardiac magnetic resonance imaging

A 48-year-old man with a history of peri-membranous ventricular septal defect (VSD) without aortic complication was admitted for dyspnoea 1 month after an unfortunate treatment with amoxicillin for a suspected acute bronchitis. The auscultation revealed a loud continuous systolo-diastolic murmur and a thrill through the precordium. The blood pressure was 140/60 mmHg, the ECG was normal except for sinus tachycardia at 90 bpm Chest X-ray showed cardiomegaly and the C-reactive protein was 25 µg/L. Trans-thoracic echocardiography showed a small peri-membranous VSD, a moderate aortic insufficiency and a high-velocity systolo-diastolic flow (5 m/s) in the pulmonary artery, but the different merging flows which confused Doppler …

Diagnosis of the left circumflex coronary artery fistula drainage into the left ventricle by echocardiographic color Doppler flow imaging

Congenital coronary fistula is consisted of a communication between a coronary artery and a cardiac chamber or pulmonary vessel. Congenital left coronary artery–left ventricle fistula is uncommon. A 41-year-old female patient admitted to our institution for evaluation of heart murmur etiology. A loud continuous murmur heard at the apex area was detected at auscultation. Echocardiography showed a large fistula draining into the left ventricle apex. Coronary angiography revealed fistula from left circumflex coronary artery to left ventricular cavity. Since the patient was asymptomatic and no concomitant cardiac pathology was detected, we advised endocarditis prophylaxis and medical follow-up.

Successful percutaneous closure of a complex coronary‐to‐pulmonary artery fistula using a detachable balloon: Benefits of intra‐procedural physiologic and angiographic assessment

A 48-yr-old woman presented with a loud continuous precordial murmur and symptoms of fatigue. Color-flow doppler imaging and nuclear magnetic resonance imaging failed to show the cause of the murmur. Diagnostic catheterization showed a large left anterior descending coronary artery to pulmonary artery fistula with impaired left ventricular wall motion. Two detachable balloons were deployed in the fistula with complete abolition of flow in the main fistula channel. A small parallel channel of the fistula, previously not appreciated due to vessel overlap, remained patent but had trivial flow as assessed by green-dye and oximetric techniques. The patient had immediate resolution of her symptoms and return of normal ventricular wall motion.

Surgical Treatment of the Ruptured Aneurysm of the Aortic Sinuses

Over the past 11 years, 51 patients (36 male, 15 female) underwent operation to correct ruptured sinus of Valsalva at the Shanghai Chest Hospital. Associated lesions were present in 36 patients. All patients had cardiac enlargement, pulmonary plethora, and prominence of the main pulmonary arterial trunk. Preoperative arterial pressure averaged 135/46 mm Hg (range, 200–96/95–0 mm Hg). At operation the cardiac chamber into which the ruptured aneurysm emptied was opened. The projecting aneurysmal sac was resected at its base, leaving a fringe of 2 to 3 mm for suturing. A double-layer suture closure was used, first a row of figure-of-eight sutures, followed by a row of buttressed mattress sutures. Forty-five patients survived operation; 6 died shortly after operation, a perioperative mortality of 11.8%. Follow-up averaged 4 years 8 months. Thirty-eight patients were symptom free and working; 7 had returned to part-time work. There were no late deaths. A grade II systolic murmur persists in 2 patients, and in 1 of them a loud continuous murmur and thrill were both noted. All patients who survived have shown remarkable reduction in cardiothoracic ratio and improvement in symptoms. These results justify early surgical intervention.

Cruveilhier-Baumgarten syndrome presenting with precordial murmur and thrill

A 47-year-old male who presented with a huge spleen and a loud continuous murmur with palpable thrill over the sternum is described. He had had several episodes of massive hematemesis prior to admission, and a traumatic arteriovenous fistula was suspected because of the past history of a blow over the left flank. Celiac arteriography was not diagnostic. Percutaneous transhepatic portography demonstrated a large collateral vein arising from the left portal branch and coursing behind the sternum.

Total anomalous pulmonary venous drainage: Case presenting with prominent right supraclavicular thrill and loud continuous murmur

A 15 year old Indian boy was discovered to have a very loud continuous murmur over the right supraclavicular region. Cardiac catheterization findings demonstrated an atrial septal defect and a left to right shunt at the level of the right innominate vein. At thoracotomy, total anomalous pulmonary venous drainage was found. The dilated vertical vein arising from the common pulmonary vein was narrowed to about 1.2 cm in diameter at its site of entry into the right innominate vein, causing blood to flow into the latter vessel in a jet-like fashion, thus producing the loud continuous murmur.

BRONCHIAL CIRCULATION IN SEVERE MULTIPLE PERIPHERAL PULMONARY ARTERY STENOSIS; CASE REPORT ILLUSTRATING THE ORIGIN OF CONTINUOUS MURMUR.

In an infant with severe, multiple, peripheral pulmonary artery stenoses angiography clearly demonstrated enlarged tortuous bronchial arteries, especially in the right lung, where a major tortuosity corresponded closely to the point of maximal intensity of a loud continuous murmur. Increased bronchial circulation may be responsible for continuous murmurs in patients with severe multiple peripheral pulmonary artery stenosis.

CARDIOAORTIC FISTULAS AND ANEURYSMS OF SINUS OF VALSALVA IN INFANCY

A report of an infant with a previously undescribed congenital malformation of the heart consisting of an aneurysm of the left sinus of Valsalva with rupture into the left atrium and associated atrial septal defects is presented. This cardiac anomaly, along with others in the literature, supplies evidence that sizable congenital aneurysms may arise from any of the three sinuses of Valsalva and may communicate directly with any of the four cardiac chambers, the pulmonary artery or the pericardial sac. Other contiguous intrathoracic structures should also be considered potential sites of ruptures. Such a consideration may prevent some instances of congenital aneurysms from being missed simply because they have not been reported. Embryologic factors are briefly discussed as is the possibility that the patient may represent a variant of Marfan's syndrome. Surgical implications are also mentioned. The patient reported presents a clinical syndrome that should be recognizable during life if the possibility of an aortic to left atrial shunt is kept in mind. The findings included evidence of heart disease soon after birth, a loud continuous murmur and thrill present maximally in the left axilla, bounding peripheral pulses and a wide pulse pressure. Roentgenograms showed marked cardiomegaly involving all cardiac chambers, a bulge in the cardiac silhouette to the left of the main pulmonary artery, and marked pulmonary vascular engorgement. There was electrocariodgraphic evidence of atrial and combined right and left ventricular hypertrophy. Cardiac catheterization revealed a peculiar pressure gradient between the left and right atria in spite of an atrial septal defect with a left-to-right shunt. Venous angiocardiograms and retrograde aortograms were not diagnostic, although a more adequate aortographic dye injection would have demonstrated the defect. Retrograde arterial catheterization should also permit an accurate diagnosis.

Pulmonary stenosis with intact ventricular septum and Fallot's tetralogy: Assessment of postoperative results by auscultation and phonocardiography

A study has been made to determine the value of auscultation and phonocardiography in assessing the result of surgery in cases of pulmonary stenosis with intact ventricular septum and Fallot's tetralogy. In cases of pulmonary or infundibular stenosis with an intact ventricular septum, a successful valvotomy or infundibular resection resulted in marked shortening and softening of the murmur and reduction in the width of splitting of the second sound. Less adequate relief of stenosis caused less shortening of the murmur and less reduction in the splitting. Criteria are given for grading the postoperative severity of the stenosis. In cases of Fallot's tetralogy, a successful valvotomy or infundibular resection (Brock operation) resulted in marked lengthening and intensification of the murmur and, frequently, the emergence of a very soft, audible pulmonary second sound widely separated (average 0.09 second) from the aortic second sound. These changes reflected increased volume rate of pulmonary flow through the stenosis and a rise in pulmonary arterial pressure. Less adequate relief of stenosis caused less prolongation of the murmur and no emergence of a pulmonary second sound. Criteria are given for grading the postoperative result. Auscultation was shown to be an excellent bedside method of predicting the surgical result of a valvotomy in the two conditions, since the change in the length of the murmur and the width of splitting developed rapidly, and accurately reflected the degree to which the stenosis had been relieved. The opposite behavior of the murmur was due to the different dynamic situation in the two conditions. The observations proved that the length of the murmur was directly related to the severity of the stenosis when the ventricular septum was intact, but inversely related in cases of the tetralogy. Following complete valvotomy under direct vision, the right ventricular pressure may fail to drop adequately because of severe subvalvular muscular hypertrophy. The resultant secondary infundibular stenosis may or may not regress over a period of time. The value of serial sound tracings in detecting the trend is emphasized. Gradual shortening of the initially prolonged murmur and narrowing of the split second sound indicate gradual reduction of right ventricular pressure and stenosis. A successful Blalock-Taussig operation for the tetralogy did not lengthen the pulmonary systolic murmur, since the stenosis was not relieved by this operation. This indirectly confirmed the view that the length of the murmur is a function of the degree of stenosis, provided that the systemic resistance remains constant. However, auscultation was of value in other respects. The development of a loud continuous murmur, especially if associated with the emergence of a recordable pulmonary second sound, ensured a good result from this operation. The use of auscultation in evaluating the result of the operation for complete repair of the septal defect and relief of the stenosis in cases of the tetralogy is discussed. The ideal end result is either a short ejection systolic murmur and narrow splitting of the second sound or no murmur at all, with normal heart sounds. The use of amyl-nitrite inhalation and phenylephrine in determining the origin of a residual systolic murmur is discussed.