Murmur Of Mitral Regurgitation Research Articles

Moderate Mitral Regurgitation Secondary to Hammock Congenital Mitral Valve Disease

A 30-year-old woman with a history of systemic lupus erythematosus and hypothyroidism . She started with dyspnea on moderate exertion, orthopnea, and a sensation of palpitations an early systolic murmur of mitral regurgitation was found. Transthoracic and transesophageal echocardiography reported hammock congenital mitral valve disease as a cause of mitral regurgitation with impaired functional class, requiring surgical valve replacement. The mitral arcade, or hammock mitral valve, is a very rare entity, even more so in the adult population, with a reported prevalence of 0.5%. It is characterized by abnormal papillary muscles connected directly to the anterior mitral.

Mitral Valve Regurgitation Murmurs—Insights from Hemoacoustic Computational Modeling

Mitral regurgitation (MR) is the leakage of blood from the left ventricle into the left atrium during systole through a mitral valve that does not close fully. A systolic murmur is produced by MR and can be used to diagnose this disease. In the current study, we use hemoacoustic simulations to characterize the features of murmurs for a range of severities relevant to chronic MR. The incompressible Navier–Stokes equations are solved using an immersed boundary method to simulate the blood flow. The resultant pressure fluctuations on the lumen wall serve as the source for the murmur, and the murmur propagation through the thorax is modeled as a 3D elastic wave in a linear viscoelastic material. The resulting acceleration on the surface of the thorax is used as a surrogate for the measurement from a stethoscope, and these characteristics of the acceleration signal are examined in detail. We found that the intensity of the MR murmur is lower at the mitral point on the precordium, as compared with the aortic and pulmonic areas. This is somewhat counterintuitive but is supported by other studies in the past. We also found that the intensity of the murmur, as well as the break frequency, are well correlated with the severity of MR, and this information can be useful for automated auscultation and phonocardiographic applications.

Clinical Evaluation of Heart Failure

A 44-year-old male with no prior cardiovascular risk factors presented with exertional dyspnea and dry cough followed by features of the right heart failure including early satiety and pedal edema. He had congestive heart failure at presentation with cardiac auscultation revealing murmurs of mitral regurgitation at the apex and tricuspid regurgitation at the lower left sternal border and aortic stenosis at the right second intercostal space. He was diagnosed as case of rheumatic heart disease based on clinical and echocardiographic assessment. The following clinical case discussion highlights some common questions that come to mind during evaluation of such patients. Physical examination findings in a patient presenting with heart failure syndrome are highlighted in particular.

Will clinical signs become myth? Developing structured Signs Circuits to improve medical students’ exposure to and confidence examining clinical signs

ABSTRACT Background Correctly eliciting and interpreting physical examination (PEx) signs contributes to successful diagnosis and is fundamental to patient care. A significant decline in the time spent acquiring these skills by medical students, and the decreased ability to elicit and recognise signs is widely acknowledged. However, organising teaching to counteract this in the busy clinical environment is challenging. We evaluated the prior exposure to clinical signs, and experience of examination teaching among a cohort of final-year medical students. Following this, we assessed the utility of a structured circuit-based approach (Signs Circuits) using hospital inpatients and junior doctors to provide high-yield PEx teaching and overcome these limitations. Materials and methods Qualitative and quantitative survey feedback, including a standardised list of 62 clinical signs, was sought from final-year medical students during their rotations at a teaching hospital in London, UK, before and after the provision of Signs Circuits. Results Prior to the course the 63 students reported limited exposure to even the most common clinical signs. For example, the murmurs of mitral and tricuspid regurgitation and the sound of lung crackles eluded 43%, 87%, and 32%, respectively. From qualitative feedback, the reasons for this included that much of their prior PEx experience had focused on the performance of appropriate examination steps and techniques in patients without pathology. During the course, students were exposed to an average of 4.4 new signs, and left with increased confidence examining and eliciting signs, and a firmer belief in their importance to diagnosis. Conclusion Medical students continue to have limited exposure to clinical signs in medical school. This signs-focused approach to PEx teaching is an effective and reproducible way to counter the deficiencies identified in signs exposure.

Employment of color Doppler echocardiographic video clips in a cardiac auscultation class with a cardiology patient simulator: discrepancy between students\u2019 satisfaction and learning

BackgroundWe have provided fourth-year medical students with a three-hour cardiac auscultation class using a cardiology patient simulator since 2010. The test results of 2010-2012 revealed that as compared with aortic stenosis murmur, students correctly identified murmurs of other valvular diseases less often. We investigated whether employment of color Doppler echocardiographic video clips would improve proficiency in identifying murmurs of aortic regurgitation and mitral regurgitation, and whether students’ favorable responses to a questionnaire were associated with improved proficiency.MethodsA total of 250 fourth-year medical students were divided into groups of 7-9 students in 2014 and 2015. Each group attended a three-hour cardiac auscultation class comprising a mini-lecture, facilitated training, two different auscultation tests (the second test being closer to clinical setting than the first) and a questionnaire. We provided each student with color Doppler echocardiographic videos of aortic regurgitation and mitral regurgitation using a tablet computer, which they freely referred to before and after listening to corresponding murmurs. The test results were compared with those in 2010-2012. The students had already completed the course of cardiovascular medicine, comprising lectures including those of physical examination, echocardiography, and valvular heart diseases, before participating in this auscultation training class.ResultsMost students indicated that the videos were useful or somewhat useful regarding aortic regurgitation (86.3%) and mitral regurgitation (85.7%). The accuracy rates were 78.4% (81.2% in 2010-2012) in aortic regurgitation and 76.0% (77.8%) in mitral regurgitation in the first test, and 83.3% (71.4%) in aortic regurgitation and 77.1% (77.6%) in mitral regurgitation in the second test, showing no significant differences as compared to 2010-2012. Overall accuracy rate of all heart sounds and murmurs in the first test and that of second/third/fourth sounds in the first and second tests were significantly lower in 2014-2015 than in 2010-2012.ConclusionsReferring to color Doppler echocardiographic video clips in the way employed in the present study, which most students regarded as useful, did not improve their proficiency in identifying the two important regurgitant murmurs, revealing a discrepancy between students’ satisfaction and learning. Video clips synchronized with their corresponding murmurs may contribute toward improving students’ proficiency.

A false left ventricular non-compaction; Late discovery of a corrected transposition of the great vessels in a 63-year-old patient

We report the case of a 63-year-old patient, admitted for NSTEMI, where the first examinations in ICU are in favor of a DCM with LV non-compaction associated with AAOCA, multimodal imaging will correct the final diagnosis by objectifying the CCTGA. 63-year-old patient, history of murmur and cardiomegaly without real follow-up or diagnosis, dyspnea on exertion for a few months, NYHA II, who presents a typical angina associated with a significant rise in cardiac biomarkers and is admitted in ICU for NSTEMI. Mitral regurgitation murmur 2/6 th, under crackles at the bases. ECG in wide LBBB, with bradycardia, axis in VR. NT pro BNP high. Pulmonary x-ray shows cardiomegaly with a rebounded left edge of the heart. The echocardiography shows a dilated LV, very trabeculated, globular appearance, with a very wide range of non-compaction, a moderate mitral insufficiency (left valve), the operator noted in his report the impossibility to image well the aortic and pulmonary outflow tract (Fig. 1). The patient has an angiogram which finds a weakly atheromatous network, however with AAOCA; birth of the LAD from the RCA and a very large and dominant CX giving 5 marginal branches of important caliber. Subsequently, a CT scan and cardiac MRI were done. First, the MRI, which finds a ventricle in a very trabecular systemic position and which clearly shows the mitro aortic rupture (major sign of TGA); as well as a wide range of late enhancement with some cryptic thrombis, the RV in the systemic position has an altered EF, LV in the upright position, with better systolic function (Fig. 2, Fig. 3). And the CCTA that signs the NCVG with an anterior aortic birth and to the left of the PA (Fig. 4, Fig. 5). The patient was treated with altered EF treatment (recommendations differ, however, on their effectiveness in CCTGA) with establishment of an ICD-CRT in a specialized center.

Unravelling the potential of phase portrait in the auscultation of mitral valve dysfunction

The manuscript elucidates the potential of phase portrait, fast Fourier transform, wavelet, and time-series analyses of the heart murmur (HM) of normal (healthy) and mitral regurgitation (MR) in the diagnosis of valve-related cardiovascular diseases. The temporal evolution study of phase portrait and the entropy analyses of HM unveil the valve dysfunction-induced haemodynamics. A tenfold increase in sample entropy in MR from that of normal indicates the valve dysfunction. The occurrence of a large number of frequency components between lub and dub in MR, compared to the normal, is substantiated through the spectral analyses. The machine learning techniques, K-nearest neighbour, support vector machine, and principal component analyses give 100% predictive accuracy. Thus, the study suggests a surrogate method of auscultation of HM that can be employed cost-effectively in rural health centres.

Mitra-clip in Transthyretin Amyloidosis Cardiomyopathy A Case Series

IntroductionNon-invasive valvular interventions have dramatically changed the management of patients with multiple complex comorbidities. Patients with cardiac amyloidosis (CA) are often considered high-risk for surgical intervention. Trans-catheter aortic valve replacement (TAVR) is tolerated in this population, however, little is known about the safety and efficacy of per-cutaneous mitral valve interventions, such as the MitraClip procedure. We present three patients with CA and mitral regurgitation (MR) who have undergone this procedure.CasesA 75-year-old man with wild-type transthyretin cardiac amyloidosis (wtATTR), atrial fibrillation with prior ablations, a Watchman device in the left atrial appendage, resection of a malignant lung nodule presented with recurrent right pleural effusions. On exam, he had a loud MR murmur, which had been present for many years. Transthoracic echocardiogram (TTE) showed moderate MR. A transesophageal echocardiogram (TEE) revealed a partial flail of the posterior leaflet of the mitral valve resulting in moderate to severe eccentric anteriorly directed MR, amenable to the placement of a MitraClip. Two MitraClips were places, which led to marked improvement in his dyspnea and a decrease in the frequency of thoracenteses for recurrent pleural effusions. A 71-year-old man with wtATTR and a permanent pacemaker was seen in follow-up with marked dyspnea on exertion and fatigue, despite being euvolemic on exam; jugular venous pressure was not elevated but there was a Kussmaul's sign. First and second heart sounds normal and no MR murmur was heard, even in the left lateral position. TTE revealed moderate MR. His symptoms appeared disproportionate to the severity of his amyloid heart disease by exam as he had no evidence of right-sided congestion. It was suspected that the degree of MR was underestimated by TTE. TEE reveled mild diffuse thickening of the mitral valve leaflets with severe, functional MR that was directed centrally. The valve anatomy was suitable for MitraClip, and he underwent successful placement of 2 MitraClips. A 88-year-old man with MR and aortic insufficiency (AI) was seen with a new diagnosis of wtATTR. He had dyspnea on minimal exertion, marked fatigue, 3 pillow orthopnea and paroxysmal nocturnal dyspnea, he was euvolemic on examination, with a Kussmaul's sign, pansystolic and diastolic murmurs. TTE showed severe MR and moderate to severe AI, confirmed with TEE, which also showed the mitral valve was suitable for MitraClip. A single MitraClip was put in situ, with trace residual MR. He noted improvement in his energy and level of dyspnea following.DiscussionIt is important to consider other cardiac pathologies that co-exist in wtATTR, which can contribute to patients’ symptoms and are amenable to intervention. These cases demonstrate that MitraClip is feasible in MR in CA with careful patient selection.

Anomalous origin of the left coronary artery from the pulmonary artery: A surgical certainty.

This study aims to assess the clinical presentation and the outcomes of a surgical correction of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). A retrospective review was carried out on the charts of six patients admitted for ALCAPA surgery at Aga Khan University Hospital, Karachi from March 2017 to May 2018.Dyspnoea, palpitation, poor feeding, fatiguability, pallor and a murmur of mitral regurgitation were the main presenting features. The pre-operative median left ventricular ejection fraction (LVEF) was 64%. Coronary reimplantation was performed in all the patients with a mitral valve repair being done in only one patient. The mea n LV EF was 66 .3%,p ost- ope rativel y. Mitra l regurgitation (MR) improved in patients post-operatively with trace in 2 patients and mild MR in one. Surgical correction by coronary re-implantation yields favourable outcomes in ALCAPA and significantly reduces the morbidity and mortality rates associated with the disease.

A-41 years old male with alcoholic cardiomyopathy at Tabanan General Hospital, Bali-Indonesia: a case report

Background: Alcoholic cardiomyopathy is a form of toxic cardiomyopathy which develops as a result of long-standing chronic ingestion of alcohol. Its clinical findings share similar features to other forms of dilated cardiomyopathy. Diagnosis can be made based on the history of long term alcohol abuse, clinical findings, and supporting diagnostic studies. This case report aims to overview alcoholic cardiomyopathy; from establishing the initial diagnosis to the treatment given for the condition.Case Description: A 41 years old male came to the emergency department unit with shortness of breath since last few days. Shortness of breath was said to be getting worse over time and progressed to breathlessness at rest. Other complaints were palpitations, fatigue, and long-standing cough. The patient was found to have a history of drinking alcohol in large quantities since 27 years ago. The blood pressure was 110/70 mm Hg, pulse rate 105 beats/min, and respiratory rate was 20 breaths/min. Slight edemas on both legs were also found. From auscultation examination, bibasilar crepitation on both lungs was found. Cardiac examination showed systolic murmur of mitral regurgitation (MR) and tricuspid regurgitation (TR). On supporting investigation, a chest x-ray showed cardiomegaly (cardiothoracic ratio; 57%). ECG examination showed sinus tachycardia and left atrial (LA) and left ventricular (LV) enlargement. Trans-thoracal echocardiographic (TTE) examination revealed; RWMA: global hypokinetic-akinetic, multi-chamber dilated and severe LV systolic dysfunction (EF 29%) and diastolic function (Grade IV (E/A Ratio>4)). Valve examination showed moderate-severe MR and moderate TR (TVG 40 mmHg).Conclusion: Alcohol cardiomyopathy is one of the most common causes of heart failure in young age and carries a poor prognosis if not treated properly. Treatment of alcoholic cardiomyopathy mainly includes total alcohol abstinence along with drugs used to treat systolic heart failure to reverse the condition and correct any nutritional deficiencies.

Attenuated form of type II mucopolysaccharidoses (Hunter syndrome): pitfalls and potential clues in diagnosis

A 7-year-old boy, born of a non-consanguineous union, presented with pain over both hips and progressive difficulty in walking for preceding 2 years. He had normal developmental milestones with satisfactory...

Prevalence and diagnostic characteristics of non-clinical mitral regurgitation murmurs in North American Whippets

ObjectivesTo assess the prevalence of functional ejection murmurs and murmurs of mitral regurgitation (MR) due to myxomatous mitral valve disease in healthy whippets; to assess the diagnostic value of auscultation to detect MR; and investigate the relationship between age and presence of echocardiographically documented MR (MRecho). AnimalsA total of 200 healthy client-owned Whippets, recruited at national shows between 2005 and 2009 were involved in this study. MethodsCross-sectional study. Dogs were examined by auscultation by one examiner and Doppler echocardiography by another, and results were compared. Prevalence of types of murmurs and MRecho were calculated and correlated to age. Accuracy of auscultation to predict MRecho was calculated. ResultsLeft-sided systolic heart murmurs were detected in 185/200 (93%) of dogs. Left apical systolic murmurs (Lapex) were detected in 57/200 (29%) and left basilar systolic murmurs (Lbase) in 128/200 of the dogs (64%). MRecho was present in 76/200 (38%) dogs. Prevalence MRecho was correlated with age (r = 0.96, p=0.0028). Mitral regurgitation detected by echocardiography was present in 12/78 (15%) of the dogs ≤ 2 years of age and in 59% of the dogs at 7–8 years old. Detection of Lapex predicted MRecho with sensitivity 65%, specificity 94%, positive predictive value 86%, and negative predictive value 81%; and accuracy improved when only dogs with more intense Lapex (grade ≥ 3/6) were considered. ConclusionsSystolic murmurs are common in North American Whippets and this breed exhibits a high prevalence of MRecho, which may be documented at a relatively early age. Whippets with non-clinical MRecho may not be identifiable by auscultation alone; echocardiographic examination may be required to exclude a diagnosis of MR. Louder heart murmurs allow more accurate localization in this population.

Giant Vegetation in a Mitral Prosthetic Valve

Forty eight-year-old-woman with history of mechanical prosthetic replacement of mitral and aortic valves in February 2005, came to emergency department with fatigue, weakness and chills since two months and dyspnea and edema of lower limbs from three days. The physical examination revealed jugular engorgement, peripheral edema, normal prosthetic clicks and mitral regurgitant murmur II/IV. The laboratory showed anemia, leucocytosis, high NT-pro BNP and high sensitive C-reactive protein. The chest X-ray with cardio megaly and veno capillary pulmonary hypertension (Figure 1). The transesophageal echocardiogram demonstrated giant vegetation in the trial side of the mitral prosthesis that prolapsed into the ventricle during diastole and small vegetations in prosthetic aortic valve (Figure 2). The blood culture showed streptococcus mitis.

Doppler Echocardiographic Follow-Up of Mitral and Aortic Regurgitation in Children and Adolescents with Subclinical and Mild Rheumatic Carditis

Abstract Background: Mild rheumatic carditis (MRC) and subclinical rheumatic carditis (SRC) are basically differentiated through auscultation of mitral regurgitation murmur. The evolution of these forms is not well established in the literature. Objective: To evaluate the evolution of mild and subclinical rheumatic carditis, considering mitral and aortic regurgitation (acute phase) and regression, maintenance or worsening of these diseases at the end of follow-up (chronic phase). Methods: Retrospective, longitudinal study, including patients with mild and subclinical rheumatic carditis. The echocardiographic evolution of mitral and aortic regurgitation was compared in both groups, considering the analysis at the end of follow-up. The Chi-square test and Kaplan-Meier survival curves were used, with significance level established at p < 0.05. Results: A total of 125 patients were included, 69 (55.2%) with subclinical rheumatic carditis and 56 (44.8%) with mild rheumatic carditis, with a mean age in the acute phase of 10.4 ± 2.6 years and, at the end of study, 19.9 ± 4.6 years. The time of follow-up ranged from 2 to 23 years (mean: 9.38 ± 4.3 years). In the acute phase, mild/moderate or moderate mitral regurgitation was more frequent in patients with mild rheumatic carditis (p = 0.001). Mild or mild/moderate aortic regurgitation was also more common in the mild rheumatic carditis group (p = 0.045). In the chronic phase, we observed that both mitral (p < 0.0001) and aortic regurgitation (p = 0.009) were more frequent in patients with mild rheumatic carditis, and survival free of rheumatic heart disease was higher in the subclinical rheumatic carditis group (p = 0.010). Residual mitral regurgitation was higher in the mild rheumatic carditis group p < 0.0001), and residual aortic regurgitation was similar in both groups (p = 0.099). Conclusion: Mitral regurgitation resolution was higher in patients with subclinical rheumatic carditis, and the involution of aortic regurgitation was less frequent and similar in both groups. (Int J Cardiovasc Sci. 2017;30(5):391-400)

Breeding Restrictions Decrease the Prevalence of Myxomatous Mitral Valve Disease in Cavalier King Charles Spaniels over an 8- to 10-Year Period.

BackgroundCavalier King Charles Spaniels (CKCS) are predisposed to myxomatous mitral valve disease (MMVD). Studies have indicated a strong genetic background.ObjectiveThe aim of this study was to evaluate the effect of a breeding scheme involving auscultation and echocardiography.AnimalsIn the Danish Kennel Club mandatory breeding scheme, 997 purebred CKCS were examined during the period 2002–2011. Each dog was evaluated 1–4 times with a total of 1,380 examinations.MethodsAuscultation and echocardiography were performed to evaluate mitral regurgitation murmur severity and degree of mitral valve prolapse (MVP). The odds of having mitral regurgitation murmur or MVP > grade 1 in 2010–2011 compared to 2002–2003 were estimated using logistic regression analysis including age and sex as covariates. Odds were estimated for dogs that were products of the breeding scheme (defined as dogs with both parents approved by the breeding scheme before breeding) and non‐products of the breeding scheme (defined as dogs with at least 1 parent with unknown cardiac status).ResultsIn 2010–2011, the odds of having mitral regurgitation murmur were 0.27 if dogs were a product of the breeding scheme compared with dogs in 2002–2003, reflecting a 73% decreased risk (P < .0001). If non‐products of the breeding scheme examined in 2010–2011 were compared with dogs in 2002–2003, no difference in odds was found (P = .49).Conclusion and Clinical ImportanceA mandatory breeding scheme based on auscultation and echocardiography findings significantly decreased the prevalence of MMVD over the 8‐ to 10‐year period. Such a breeding scheme therefore is recommended for CKCS.

Worsening Dyspnea in a 38-Year-Old Woman

A 38-year-old Hispanic woman with longstanding exertional dyspnea sought medical attention because of the recent onset of paroxysmal nocturnal dyspnea. Cardiac physical examination revealed murmurs of mitral stenosis and regurgitation, a prominent a wave in the jugular venous pulse, and a loud pulmonic valvular closure sound. An electrocardiogram showed sinus rhythm, left atrial enlargement, right axis deviation of the QRS complex, and an R/S ratio in lead V1 > 1.0 with a negative T V1, suggesting right ventricular hypertrophy (Figure 1). Figure 1. Electrocardiogram soon after admission showed left atrial enlargement (negative terminal P-wave deflection in lead V1 ≥ 0.1 mV and 0.04 s in duration) (2) and right ventricular enlargement (right axis deviation of the QRS complex and R/S ratio ... At cardiac catheterization, the pressures (mm Hg) were 64/30 in the pulmonary artery, 65/8 in the right ventricle, a mean of 7 in the right atrium with a waves of 10 and v waves of 7, a mean of 26 with a waves of 17 and v waves of 38 in the pulmonary arterial wedge position, and 96/6 in the left ventricle. The cardiac output by thermodilution was 3.4 L/min, which together with a 16 mm Hg mean diastolic pressure gradient between pulmonary arterial wedge and left ventricle gave a calculated mitral valve area of 0.7 cm2 (Figure 2). Angiocardiography revealed mild mitral regurgitation, trivial tricuspid regurgitation, and no aortic regurgitation. Figure 2. Simultaneous pulmonary arterial wedge and left ventricular pressure tracings showing a 16 mm Hg mean diastolic pressure gradient across the mitral valve (MVG). The pressure scale on each side of the tracing is in mm Hg. DFP indicates diastolic filling ... Rheumatic heart disease is the cause of mitral stenosis in most adults. Because of the steady decrease in the incidence of acute rheumatic fever over the past 75 years in the United States, mitral stenosis is now uncommon here and is most often seen in older patients and, as in this patient, in immigrants from less developed countries (1). Clinical evaluation is usually sufficient for making a diagnosis of mitral stenosis (1). The electrocardiogram can be helpful in this regard, but the history, physical exam, chest radiograph, and especially the echocardiogram are usually more helpful. Nevertheless, electrocardiographic evidence of left atrial enlargement and right ventricular hypertrophy in a dyspneic young immigrant woman from an underdeveloped country puts mitral stenosis toward the top of the list of diagnostic possibilities.

Aneurysm of the Left Coronary Artery in Postoperative Bland-White-Garland Syndrome.

We report a case of anomalous left coronary artery from the pulmonary artery (ALCAPA) or Bland-White-Garland syndrome, present the challenges of performing a differential diagnosis, and discuss the treatment of the syndrome. Although ALCAPA is a rare congenital heart disease, it is one of the most common causes of myocardial ischemia in childhood and presents a diagnostic challenge. A four-year-old girl was referred to a pediatric cardiologist for evaluation of mitral valve regurgitation murmur and heart failure. The transthoracic echocardiogram demonstrated the left coronary artery (LCA) not arising from the aorta, presence of coronary collateral circulation, and moderate mitral valve regurgitation. ALCAPA was confirmed using angiotomography. The LCA was surgically reimplanted into the aorta. After 3 years of postoperative follow-up, the patient developed an LCA aneurysm. Diagnosis of cardiac ischemia in childhood remains a challenge, and careful evaluation of coronary arteries on the echocardiogram is an important tool. In this report, we present a case of ALCAPA with an uncommon postoperative outcome.

PO-0231 Cardiac Involvement, Major Problem In Human Immunodeficiency Virus Infection In Children

Objectives The present the main clinical aspects and diagnostic of cardiac involvement induced by human immunodeficiency virus infection in children. Methods Patients: 51 children (2–16 years) with HIV infection/AIDS in various stages of evolution, with diverse symptoms affecting many organs. Evaluation of patients:clinical, ECG, Chest X ray, echocardiography (echo). Results 60% of patients were included in group P2f clinical staging by clinical exam and CD4 lymphocytes values. Signs of cardiac involvement: heart failure (11 cases), tachycardia (20 cases), deafness of the heart sounds ± gallop rhythm ± systolic murmur of mitral regurgitation (12), dyspneea (14 cases), other non-symptomatic (14) or with signs of others diseases. ECG : disturbances of ventricular repolarisation. Rx. CT: cardiomegaly (30% cases) ± aspects of pulmonary infections. Echo exam: cardiac involvement (66% cases): dilated cardiomyopathy, the most severe changes (14 cases), pericarditis (10), isolated dilation of the left and right ventricle (6), LV diastolic dysfunctional (14 cases), pulmonary hypertension (6). The severity and incidence of cardiac disease was associated with significant reduction of CD4 value Conclusion By the high incidence (66% of cases) and severity of clinical manifestations, cardiac suffering during HIV infection/AIDS is one of the most important problems of these patients. Cardiological evaluation of patients is necessary in all the stages of the infection, even non-symptomatic, for the diagnosis and follow-up of evolution. Echocardiography is the most sensitive noninvasive method for highlighting cardiac damage in these patients.

Electrocardiogram in a 28-Year-Old Woman with Dyspnea on Exertion

A28-year-old HIV-infected woman with dyspnea on exertion for 6 months had no history of acute rheumatic fever or opportunistic infections and no family history of heart disease. Her CD4 count 3 months earlier was 473/μL, and she was adherent with her antiretroviral therapy. On physical examination her neck veins were normal, as were her carotid pulses. The chest was clear to auscultation. A 1+/4+ left parasternal (right ventricular) lift was felt, and the left ventricular impulse was normal. The first heart sound was loud and split. The second heart sound was loud and palpable in the second left intercostal space. Heard at the cardiac apex were a soft pansystolic murmur of mitral regurgitation and an early low-medium pitched third heart sound immediately followed by a typical diastolic murmur of mitral stenosis. An electrocardiogram was normal except for signs of left atrial enlargement: a negative terminal portion of the P wave in lead V1 ≥ 0.1 mV in amplitude and ≥ 0.04 seconds in duration (2); P waves in leads II, III, aVF, V3, and V4 ≥ 0.12 seconds in duration (3); and bifid with >0.04 seconds between the 2 peaks (4) in leads III and V3 (Figure). Figure. Electrocardiogram in a 28-year-old woman with exertional dyspnea for 6 months. See text for explication. An echocardiogram explained how a patient with a third heart sound could have a typical murmur of mitral stenosis by demonstrating a large left atrial myxoma that fell into the mitral orifice early in each diastole causing a “tumor plop” followed by a mitral stenosis murmur because the orifice of the valve was almost completely occluded. The mean diastolic pressure gradient across the mitral valve was 18 mm Hg as measured by echo-Doppler. Because the hemodynamics of left atrial myxoma and mitral stenosis are so similar, it is not surprising that both the physical exam and the electrocardiogram would be similar in the two conditions, with P waves suggesting left atrial enlargement being early electrocardiographic findings in both. The patient underwent uneventful operative removal of a 5 × 4 × 8.5 cm left atrial myxoma.

Imaging systolic and diastolic heart murmurs in hypertrophic cardiomyopathy

Muscular obstruction in hypertrophic cardiomyopathy can occur not only in systole, but also in diastole. Here we report a case of hypertrophic cardiomyopathy in a middle-aged lady: echocardiography and cardiovascular magnetic resonance confirmed the diagnosis of hypertrophic cardiomyopathy with significant systolic and diastolic midventricular obstruction, corresponding to the murmurs audible in mid-systole and early-diastole respectively. Moreover, the mid-systolic murmur was clearly distinguishable from the mitral regurgitation murmur, which was audible throughout systole (pan-systolic) and likely related to systolic anterior motion of the mitral chords; similarly, the early-diastolic heart murmur due to diastolic obstruction was better audible at the apex and clearly distinguishable from common diastolic murmurs due to aortic regurgitation. Echocardiography (with Doppler recordings) and magnetic resonance (with turbulence flows at steady state free precession imaging) allowed a detailed visualization of each audible murmur (systolic obstruction, mitral regurgitation, diastolic obstruction). In particular, while systolic obstruction has been extensively studied in hypertrophic cardiomyopathy, only very few reports about diastolic obstruction exist, describing either a normodirected midventricular diastolic obstruction (forward flow) similar to this case or a paradoxical midventricular diastolic obstruction (backward flow) in patients with an apical aneurysm emptying during early diastole into the left ventricular base through a narrow midventricular channel. Whether diastolic obstruction implies worse prognosis or requires specific treatment, deserves further research.