Opening Snap Research Articles

Cardiac manifestations of the mucopolysaccharidoses.

The cardiovascular manifestations of the mucopolysaccharidoses (MPS) have not been well characterized. We studied nine children with various forms of MPS, using noninvasive cardiac diagnostic techniques. The echocardiograms of two brothers with Type I H/S MPS showed slow mitral valve early diastolic closure velocities (MVEDC) (18, 29 mm/sec) consistent with mitral stenosis. Each had a soft opening snap, low frequency presystolic murmurs and X-ray evidence of calcific mitral stenosis. Three patients with Type II A MPS had echocardiographic evidence of impaired left ventricular function, suggesting the presence of myocardial damage. One of these had an abnormal electrocardiogram; non had murmurs. No cardiac abnormalities were discovered in two patients with Type III A and IV MPS. One patient with Type VI A MPS had presystolic, holostolic and early diastolic murmurs. A soft opening snap was recorded. The echocardiogram showed a slow MVEDC (18 mm/sec) and a slightly enlarged left atrial dimension (2.2 cm/m2). In summary, noninvasive studies are useful in evaluating patients with MPS. Type I H/S and Type VI A patients may show evidence of valvular deformity, the former associated with mitral valvular calcification and the latter with both aortic and mitral valve involvement. Type II A patients have muscle function abnormalities and Type III A and IV are shown by noninvasive methods to be free of cardiovascular abnormalities.

Late systolic murmur of rheumatic mitral insufficiency

Of 184 patients with acute rheumatic fever and associated mitral insufficiency encountered during a 15 year period, 34 manifested a mid-late systolic murmur or a nonejection click, or both, during the course of follow-up. The mid-late systolic murmur later disappeared in four patients whose condition is now considered normal. In one of the four, systolic prolapse of the mitral valve was demonstrated on an angiocardiogram obtained when the systolic murmur was present. Since disappearance of the murmur there has been no evidence of systolic prolapse on meticulous echocardiographic study of the mitral valve. In another child with angiographically demonstrated systolic prolapse of the mitral valve the systolic murmur has also disappeared, but systolic prolapse is still evident on echocardiographic study. None of the 34 patients with a mid-late systolic murmur manifested the T wave abnormalities commonly associated with the familial variety of mitral valve prolapse.

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.

The Clinical Syndrome of Atrial Myxoma

Seventeen cases of atrial myxoma were reviewed to delineate features that facilitate the correct diagnosis. Each patient had features of a classic triad of obstructive, constitutional, and embolic effects. Common findings included a short (two years or less) clinical course in 10, no rheumatic fever in 16, syncope or paroxysmal dizziness in 9, systemic emboli with sinus rhythm in 3, and symptoms of systemic illness in 10. On auscultation, left atrial myxoma mimicked rheumatic mitral valve disease, but discriminating clues were variable auscultatory findings in five patients and an accentuated S, or apparent opening snap with notable mitral regurgitation in four. Features of systemic illness, anemia, or leukocytosis in ten patients and a high sedimentation rate or elevated immunoglobulin level in eight suggested myxoma. Angiography confirmed the preoperative diagnosis. As long as 15 years since surgery, there have been no recurrences following definitive tumor resection at our hospital. (JAMA230:695-701, 1974)

Sounds of the heart in diastole

Cardiac diastole usually is acoustically silent even though several hemodynamic events take place in this phase of the cardiac cycle. In some healthy subjects and in many patients with cardiovascular alterations one or more “extra” heart sounds may be heard in diastole, and in them the distinction between normal and abnormal heart sounds must be established. In general, diastolic sounds may be spontaneous in nature or iatrogenic, that is, a consequence of replacement of the atrioventricular (A-V) valve with a caged-poppet prosthesis or a result of pervenous pacemaker implantation. The majority of the sounds emanate from the chambers of the heart. This presentation discusses normal and abnormal ventricular filling sounds, opening snap, “tumor plop,” pericardial knock, prosthetic A-V valve click and pacemaker-induced sound.

Echocardiography in the Diagnosis of Ebstein's Anomaly

This study presents four patients with Ebstein's malformation of the tricuspid valve, with hemodynamic, phonocardiographic and echocardiographic investigation. The echocardiogram demonstrated right atrial enlargement and an “atrialized” right ventricular area, pronounced anterior movement of the tricuspid valve with low ejection fraction slope values and a greater than normal delayed closure and opening as compared with the mitral valve. Abnormal septal motion was found in all the cases. Echocardiographic studies, when compared with phonocardiographic and catheterization data, show that an early systolic sound occurs when the tricuspid valve reaches the limit of its systolic excursion, after functional closure of the valve. Early diastolic sounds were generally tricuspid opening snaps.

Subacute Bacterial Endocarditis in a Patient with Isolated, Nonejection Systolic Click but without a Murmur

An 18-year-old college girl with an isolated, late systolic, nonejection click developed subacute bacterial endocarditis. Her course was uncomplicated except for the development of a late systolic murmur following the click. The importance of prophylaxis against endocarditis in patients with nonejection, systolic clicks, even in the absence of a murmur is emphasized.

Origin of heart sounds. Results of frequency analytical studies on heart sounds

Applying mathematical frequency analysis to phonocardiographic records the author could show that: 1. heart sounds are not composed of noises of short duration, as supposed hitherto, but consist of short complexes comprising a fundamental frequency and wholefigured upper partials; 2. the harmonic upper partials of first heart sound, second heart sound, and mitral opening snap have common zero-crossing points with the fundamental frequency, which means that there is phase balance between fundamental frequency and hormonics; 3. because of statements 1 and 2 one can conclude that spheric sound emitters are the sources of heart sounds; 4. a proposed vibration model is in aggreement with the statements 1 to 3. A vibration equation is derived from this model; 5. there is a strong correlation between the fundamental frequency of the first part of first heart sound and heart volume as well as between the fundamental frequency of mitral opening snap and volume of the left atrium; 6. variation in size of the left ventricle causes corresponding variations of the fundamental frequency of the first part of first heart sound; 7. in patients with mitral stenosis and atrial fibrillation it seems possible to evaluate the degree of stenosis by the variation of the fundamental frequency of the first heart sound; 8. the membranes of the heart valves are not the sources of heart sounds; 9. there was no evidence for the existence of a so called “pure muscle tone”.

Production Mode of Systolic Clicks Due to Mitral Cusp Prolapse

Phonocardiograms in three frequency bands confirm resemblance of systolic clicks due to mitral cusp prolapse to opening snap of mitral stenosis. Both sounds are brief and higher pitched than first, second, or third heart sounds. A similar sound was evoked by tensing anterior mitral leaflets from commissure to commissure, parallel to the annulus, while tensing from the papillary muscles to the annulus evoked sounds similar to the first sound in pitch and duration. Lateral tension on the anterior cusp is suddenly applied in patients with systolic prolapse of the mitral valve when the posterior cusp is pulled away. This leaves the anterior cusp without counter-pressure at the line of closure and it must expand to its maximal area under full systolic tension.

The Apexcardiogram in Patients with Systolic Prolapse of the Mitral Valve

Fifteen patients with the clinical and phonocardiography finding of a nonejection click initiating a late systolic murmur had apexcardiograms (ACG) performed. In every case, the inward motion of the apex normally inscribed between aortic valve opening and closure was interrupted by either a notch or a second systolic wave, the onset of which occurred at the time of the click. This ACG finding was associated with a double apical systolic impulse in some patients. Therefore, systolic prolapse of the mitral valve has to be excluded from other conditions that cause a double apical impulse.

Echocardiographic studies to explain opening snaps in presence of nonstenotic mitral valves

An opening snap is most often associated with either mitral or tricuspid valvular stenosis. A study using the simultaneous graphic recording of mitral valve motion by echocardiography along with the phonocardiogram and the left ventricular apex cardiogram has provided evidence supporting the existence of a mitral valve opening snap in the following cardiac conditions: (1) tricuspid atresia with a large atrial septal defect; (2) idiopathic second and third degree heart block; (3) ventricular septal defect; (4) mitral regurgitation; (5) thyrotoxicosis; and (6) tetralogy of Fallot occurring after a Blalock-Taussig procedure. In each condition the opening snap occurred 90 to 110 msec after appearance of the aortic component of the second heart sound on the phonocardiogram, and it coincided with the point of maximal descent of the anterior leaflet of the mitral valve as shown by the echocardiogram and the 0 point on the apex cardiogram. The pulmonic closure sound was identified in each case as a separate sound. An exaggerated third heart sound was thought not to be the cause of this high to mid-frequency diastolic sound since it consistently occurred before the peak of the rapid filling wave. None of the patients had mitral stenosis, as determined by cardiac catheterization in 2 patients and by echocardiography in 4. The common hemodynamic factor responsible for the abnormal sound seemed to be excessive blood flow across the mitral valve into a normal left ventricle. This study confirms previous impressions that opening snaps may be found in a variety of apparently unrelated cardiac conditions, and it demonstrates yet another use for echocardiography.

The value of the ultrasonic Doppler method and apexcardiography as reference tracings in phonocardiography

The exact timing of the opening of the mitral valve and of atrial contraction was obtained by utilizing the ultrasonic Doppler. These signals were used as reference points in phonocardiography for the differentiation of the diastolic heart sounds and compared to the ACG utilized for the same purpose in 62 patients. The Doppler signal coincided with the opening snap in all patients with mitral stenosis while the 0 point of the ACG usually followed the opening snap by a time interval of up to 20 msec. The third heart sound bore a very close relationship to the end of the rapid filling wave of the ACG. The fourth heart sound was related to the atrial component of the Doppler tracing as well as the A wave of the ACG. Satisfactory Doppler tracings were obtained in all 62 patients while in 11 of these patients a satisfactory ACG could not be obtained. The ultrasonic Doppler method is a noninvasive method that can be used as a reference tracing in phonocardiography especially when a satisfactory ACG cannot be obtained. The tracings can be recorded with minimal delay and at no risk or discomfort to the patient. The ultrasonic Doppler method is the most reliable and accurate noninvasive method for the identification of the opening snap and timing of the mitral opening while the ACG is more reliable for the identification of the third heart sound.

Echocardiographic Studies to Explain Mitral-Valve-Opening Snaps from Nonstenotic Mitral Valves.

Excerpt An opening snap is thought to be diagnostic of either mitral or tricuspid valve stenosis. A study using the simultaneous graphic recording of mitral valve motion by echocardiography along w...

Asymmetrical hypertrophic cardiomyopathy simulating mitral stenosis.

Hypertrophic cardiomyopathy usually involves the left ventricle more severely than the right, and when asymmetrical may produce the syndrome of idiopathic subaortic stenosis. Less commonly, clinical manifestations of inflow-tract obstruction predominate and produce a syndrome that may be mistaken for mitral stenosis, principally because of an apical diastolic rumbling murmur. The probability of this diagnostic error and the risk of a consequent unnecessary operation can be reduced by appreciating the significance of the clues to left ventricular disease revealed by the electrocardiogram and the chest roentgenogram. Furthermore, proper timing of the heart sounds differentiates the protodiastolic filling sound of cardiomyopathy from the opening snap of mitral stenosis. The correct diagnosis is established following ventriculographic and hemodynamic studies.

Etiology and electrocardiographic features of the billowing posterior mitral leaflet syndrome: Analysis of a further 130 patients with a late systolic murmur or nonejection systolic click

The etiology of the mitral valve pathology in 130 patients with either a late systolic murmur (twenty-six), a nonejection systolic click (sixty-three) or both (forty-one) is analyzed. In the majority (eighty patients) no cause could be found, but in twenty-three of these a familial factor was present, and in eighteen others (including two sisters) there was association with congenital heart disease, in particular a secundum atrial septal defect. Other etiologic factors included the Marfan syndrome, rheumatic endocarditis, hypertrophic obstructive cardiomyopathy and ischemic heart disease. In eight patients the appearance of the nonejection click followed a mitral commissurotomy. Twelve patients had the characteristic electrocardiographic pattern of posteroinferior myocardial “ischemia,” which is not infrequently encountered in the billowing posterior mitral leaflet syndrome, and six others had nonspecific abnormalities, including S-T segment and T wave changes and prolongation of the P-R interval. Ventricular or supraventricular premature contractions occurred at rest in nine patients. Multifocal ventricular premature contractions occurred after effort in six of the fifty patients subjected to strenuous exercise, particularly in those with the electrocardiographic pattern of posteroinferior myocardial ischemia. The mechanism of production of the myocardial pathology in patients with the billowing posterior mitral leaflet remains unknown, but the view is favored that the pathology of the leaflet precedes that of the papillary muscles in the majority of patients.

Clinical studies on apexcardiogram. I. Analysis of apexcardiogram in various kinds of heart diseases.

Apexcardiogram (ACG) in 324 patients with various circulatory disorders and 20 young healthy males were analysed under classification by Benchimol and Dimond, Ahuja and Miguel. Average value of the A Wave Ratio (AWR) was relatively high, in so-called Primary Myocardial Disease and congenital heart diseases. Large A wave was observed in the patients with IHSS, third or fourth sound, observed in ischemic heart diseases, and especially Primary Myocardial Disease. Isometric Contraction Time (ICT) by the method of Ahuja was slightly longer in AS than AI, and in MI than MS, respectively. In mitral valvular diseases, O point coincided with opening snap in almost one half of the cases, but pre-existed in else. Inclination of the Diastolic Filling Wave was significantly higher in MI than MS. Relationship between apexcardiogram and esophagocardiogram in cardiovascular diseases were referred.

A new pharmacologic phonocardiography by the use of angiotensin

A potent vasoconstrictive action and the hemodynamic consequences of angiotensin, selective to the systemic circulatory system, were applied in functional phonocardiography in place of methoxamine or phenylephrine. As with methoxamine or phenylephrine, regurgitant murmurs occurring in the left heart increased significantly with angiotensin while right-sided heart murmurs remained unchanged. Angiotensin, however, is much more advantageous than methoxamine, because of the much sharper action of only a few minutes' duration without any untoward effect, making it useful even in the outpatient clinic. Furthermore, angiotensin intensified the mitral opening snap in several cases of mitral-valve failure, not significantly affecting the II a-opening snap interval and the heart rate, and is indicated to be useful as a new device for detecting opening snap.

Postexercise arrhythmias in the billowing posterior mitral leaflet syndrome

The syndrome of late systolic murmur, nonejection click, billowing posterior leaflet, and mild mitral regurgitation is well documented. Electrocardiographic abnormalities consisting of S-T and T-wave changes suggestive of posteroinferior myocardial ischemia are not uncommon. Sudden death, sometimes related to effort, has occasionally occurred. Twelve patients with a late systolic murmur, a nonejection click or both, 5 of whom had an abnormal resting ECG, were subjected to strenuous exercise and the ECG recorded immediately and at intervals thereafter. A striking feature in 3 patients was the appearance, 1 to 2 minutes after cessation of exercise, of numerous multifocal ventricular extrasystoles. Postexercise ECG's after oral propranolol in 2 patients and propranolol plus diphenylhydantoin in the third patient showed disappearance of the ectopic beats. It is suggested that sudden death in this syndrome may be due to ventricular fibrillation preceded by multifocal ventricular extrasystoles. We recommend that a postexercise electrocardiogram be done in all patients with a late systolic murmur or nonejection click. Although papillary muscle dysfunction, secondary to ischemia, may be the cause of billowing of the mitral leaflet in some instances, we believe that leaflet or chordal pathology is the primary abnormality in the majority of cases of this syndrome. The nature of the myocardial pathology remains unknown.

Sound, pressure and motion correlates in mitral stenosis

Fifteen patients with mitral stenosis were studied during diagnostic cardiac catheterization in an effort to correlate the heart sounds of mitral stenosis with the corresponding mitral valve motion and intracardiac pressure events. In seven patients, mitral valve motion during cineangiography was correlated with a simultaneously recorded external phonocardiogram using the cine trace system. In seven additional patients, mitral valve motion during cineangiography was correlated with simultaneous sound and pressure events recorded with a catheter tip micromanometer using the cine trace system. The mitral component of the first heart sound occurred when the ascent of the mitral valve abruptly stopped at the point of maximal upward excursion which was coincident with the left atrial C wave. The mitral opening snap occurred when the descent of the mitral valve was abruptly halted at the point of maximal downward excursion which was coincident with the notch on the y descent of the left atrial pressure. Simultaneous equisensitive micromanometer pressures were obtained from the left atrium and the left ventricle in three patients. The mitral first heart sound occurred 18 msec after pressure crossover while a pressure gradient of 14 mm Hg developed between the left atrium and the left ventricle. The opening snap occurred 28 msec after pressure crossover while a pressure gradient of 11 mm Hg developed between the left atrium and the left ventricle. No flow occurred across the mitral valve until the point of maximal descent was reached. Following the opening snap, the initiation of flow into the left ventricle corresponded with the onset of the diastolic murmur. Subtle pressure transients recorded from the left atrium, left ventricle and central aorta using the catheter tip micromanometer were coincident with the mitral first heart sound and opening snap and could be clearly identified in the first derivative of these pressures. These data support the principle that sudden acceleration and deceleration of blood within the cardiohemic system is responsible for the production of heart sound transients. At the point of maximal ascent and descent of the mitral valve, a sudden change in the momentum of blood as it is arrested by the stenotic mitral valve sets the entire cardiohemic system into vibration. The higher frequency vibrations are appreciated as the mitral first heart sound and opening snap, whereas the lower frequency components are recorded as pressure transients.

Opening snap of the tricuspid valve in atrial septal defect: A phonocardiographic and reflected ultrasound study of sounds in relationship to movements of the tricuspid valve

Opening snap of the tricuspid valve in atrial septal defect: A phonocardiographic and reflected ultrasound study of sounds in relationship to movements of the tricuspid valve