Systolic Click Research Articles

Detection of Phonocardiogram Event Patterns in Mitral Valve Prolapse: An Automated Clinically Relevant Explainable Diagnostic Framework

The objective of this study is to develop an automated clinically relevant diagnostic framework for a group of cardiovascular diseases, namely, valvular heart diseases (VHDs). Though for clinical screening, manual auscultation using a stethoscope is the current standard, it is losing its significance due to the demand for years of skill and experience from the clinician. While the physiological location for capturing heart sound signal, called phonocardiogram (PCG), is standardized, the measurement and classification of PCG into different VHDs need automation to redeem its importance. Recent research on the applicability of machine learning (ML) and deep learning (DL) in PCG-based classification of VHDs produced high accuracy, but often loses the clinical explanation behind them, and hence, often not endorsed by the healthcare fraternity. The proposed study attempts to bridge this gap with two types of clinically explainable automated frameworks: 1) one utilizes clinically relevant PCG features in statistical rule-based models (RBM) as well as ML-based decision-tree (DT) frameworks; 2) the other uses time-frequency representation (TFR) with 2-D convolution neural network (CNN) and signal of PCG cycle with 1-D CNN, reveals similar clinically explainable intelligence. As a case study, mitral valve prolapse (MVP) − a specific VHD categorized into three severity subclasses of early systolic click (ESC), ESC with murmur (ESCM), and mid-SC with murmur (MSCM). The signature events (S1, S2, SC, and murmur) in PCG are segmented using a novel Teager–Kaiser energy operator and continuous wavelet transform (TKEO-CWT) algorithm. Clinically relevant intra- and inter-event features like duration, intensity, and pitch (dominant frequency) in RBM and DT produced 100% and 98.6% accuracies, respectively. Interestingly, gradient class activation (Grad-CAM) of 1-D and 2-D CNN with PCG signal and scalogram as input also converges to the same clinical explanations. Thus, the proposed clinically explainable frameworks demonstrate excellent potential in measurements and classifications in future clinical diagnostic products.

How useful is electrocardiography in children with cochlear implantation?

Hearing loss is an important health problem in children and cochlear implantation is used in its treatment. In addition, in children with hearing loss, accompanying renal, neurological, structural and cardiac conductive pathologies can often accompany. In this study, it was aimed to evaluate the electrocardiographic findings, especially QT duration in children who underwent cochlear implantation. The data were obtained from the medical records of our hospital, which is a tertiary referral cochlear implant center. All children who had cochlear implantation surgery due to sensorineural hearing loss and admitted to our hospital for speech therapy between 2019 and 2020 were evaluated with 12-channel ECG. Sixty children (15 girls and 45 boys) with a mean age of 6.5 years were analyzed. Children with a history of heart disease were excluded. In cardiac examinations, five (8.3%) had systolic murmur, four (6.6%) had mid systolic click, and two (3.3%) had stiffening in the first heart sound. Abnormalities were detected in 25% (n=15) of the electrocardiograms. The most common ECG abnormalities were prolonged QT in 4 cases, left ventricular hypertrophy in 3 cases, left axis deviation in 2 cases, and T wave changes in 2 cases. Long QT syndrome (3.3%) was diagnosed in 2 of the cases with long QT. This study demonstrates the need for electrocardiography and cardiac examinations in children undergoing cochlear implantation for hearing loss. These cases should be evaluated especially in terms of the presence of cardiac arrhythmias and potential for fatal ion channelopathy.

A Case of Mitral Annular Disjunction Combined with Ventricular Arrhythmias

The article presents a clinical case of a combination of mitral valve prolapse (MVP), mitral annular disjunction (MAD), and ventricular arrhythmia. The presence of MAD worsens the prognosis in MVP and predisposes to life-threatening ventricular arrhythmias. In a 42-year-old patient, MAD was detected during echocardiography to determine the indications for surgical correction of mitral insufficiency in MVP. Severe myxomatous degeneration of the mitral valve leaflets, polysegmental prolapse, and typical auscultatory pattern (systolic click followed by systolic murmur in the second half of systole) were the indications for the targeted search for MAD. Multi-day (ECG) monitoring recorded nonsustained ventricular tachycardias and premature ventricular complexes (PVCs). Cardiac magnetic resonance imaging was performed for confirmation the diagnosis and searched for left ventricular myocardial fibrosis accompanying MAD. Finally, MAD was confirmed, but myocardial fibrotic changes were not detected. Owing to the absence of myocardial fibrosis, the patient was treated conservatively with a beta-adrenoblocker (25 mg/day slow-release metoprolol succinate) in combination with 25 mg/day allaforte. Repeated 24-h ECG monitoring did not detect ventricular tachycardias and nonsustained registered a significant decrease of number of PVCs. The patient is followed up prospectively due to high risk factors for fibrosis and worsening prognosis, which may require surgical correction of the existing disturbances and/or implantation of a cardioverter-defibrillator.

Synchrosqueezed Transform based Click Event Segmentation in Phonocardiogram of Mitral Valve Prolapse.

Phonocardiogram (PCG) signal of the mitral valve prolapse (MVP) patients is characterized by transient audio events which include a systolic click (SC) followed by a murmur of varying intensity. Physicians detect these auscultation clues in regular auscultation before ordering expensive echocardio-graphy test. But auscultation is often error prone and even physicians with considerable experience might end up missing these clues. Therefore developing machine learning techniques to help clinicians is the need of the hour. A segmentation technique using Fourier synchrosqueezed transform (FSST) features with a long short term memory (LSTM) network is proposed in this study. An accuracy of 99.8% on MVP dataset demonstrates the potential of the proposed method in clinical diagnosis.

ANALYSIS OF HEART SOUND SIGNALS IN EBSTEIN'S ANOMALY

Ebstein's anomaly is an abnormality in the pediatric heart disease group. The anomaly is described as a structural defect by considering the whole heart. It can be manifested by typical symptoms in auscultation and can be detected with other diagnostic methods such as ECG. Systolic ejection click and murmur are the most important symptoms in the diagnosis of disease. In this study, heart sound signal recorded from a 13-year-old patient was analyzed with different numerical methods along with a normal heart sound signal. The signals were first examined in the time plane and findings in auscultation were observed. The frequency components of the signals were then obtained. Additional frequency components emerged in findings of disease in this plane compared to the normal one. Spectrograms enable to observe the differences in time frequency and amplitude components. Bispectral analysis was performed as a high order spectral analysis method by diversifying the analysis. In bispectral analysis of the anomaly, click and murmurs are manifested by equiphase surfaces distributed at high frequencies.Lastly, the power spectrum density of the signals were examined. The decrease in the additional power peak and power rating of the diseased signal was remarkable.

PULMONARY ARTERY ANEURYSM- IDIOPATHIC

SUMMARY
 A 28-years old female presented with complaints of palpitations and mild retrosternal chest pain. CXR showed a prominent Pulmonary artery. A TTE study revealed a huge main pulmonary artery whereas the branches were of normal size. CT angio revealed aneurysmal main Pulmonary artery and normal sized branches. No concomitant etiology was noted, hence labelled as “idiopathic pulmonary artery aneurysm”.
 CASE DESCRIPTION
 A 28-year-old female presented with retrosternal chest pain and palpitations for the last six months. Multiple systolic clicks and murmur III/VI heard in the pulmonary area. ECG was unremarkable. Chest X-Ray showed no cardiomegaly and a prominent pulmonary artery. Transthoracic echocardiography showed aneurysmally dilated main pulmonary artery (size: 5.7cm). Pulmonary valve was thickened with mild regurgitation. CT angiogram demonstrated dilated main pulmonary artery (axial dimension: 5.8cm) with normal-sized branches (Figure1). Immunological workup was negative. She was advised surgical intervention which she agreed to pursue soon at a tertiary care hospital near her hometown.
 LEARNING POINTS
 
 Pulmonary artery aneurysm has an incidence of 1 in 14,000, (based on 109,571 autopsies).1
 The maximum normal diameter of MPA is 29mm in males and 27 mm in females. For interlobar branches the maximum size it 17 mm.2 If the size exceeds 4 cm it is “aneurysmal” which may be true of false.
 PAA could be congenital due to Eisenmenger’ syndrome, Pulmonary valve stenosis and absent pulmonary valve syndrome. Connective tissue disorders (Marfan’s syndrome, alpha-1 antitrypsin deficiency and Ehlers-Danlos syndrome) and autoimmune disorders (Behcet’s disease and Hughes-Stovin syndrome).3
 Acquired causes include PAH, auto-immune disease (vasculitis), trauma infections, malignancy and idiopathic.
 For intervention no consensus of opinion is available. However expert opinion recommends it when the patient becomes symptomatic or pulmonary artery diameter exceeds 5 cm to 6 cm.
 
 QUESTIONS WITH ANSWERS
 
 Question 1: Is there any difference in the measurement of PA size by echocardiography and CT?
 Question 2: What is the usual site of dissection in PAA?
 Question 3: In Pulmonary arterial tree what is the most frequent site of aneurysm?
 Question 4: Some cases of pulmonary artery aneurysms can be managed medically- Y/N?
 Question 5: The technique of choice for diagnosing PA aneurysm is pulmonary angiography or CT angiogram?
 
 Answers
 
 Question 1: Yes
 Question 2: Main PA
 Question 3: Right lobar artery
 Question 4: Yes
 Question 5: CT angiogram
 
 References
 
 Deterling RA Jr and Clagett OT. Aneurysm of the pulmonary artery; review of the literature and report of a case. Am Heart J. 1947;34:471-99.
 Truong QA, Massaro JM, Rogers IS, Mahabadi AA, Kriegel MF, Fox CS. Reference values for normal pulmonary artery dimensions by noncontrast cardiac computed tomography: The Framingham Heart Study. Circ Cardiovasc Imaging 2012;5:147-54.
 Agarwal S, Chowdhury UK, Saxena A, Ray R, Sharma S, Airan B. Isolated idiopathic pulmonary artery aneurysm. Asian Cardiovasc Thorac Ann. 2002;10(2):167-9.

Bicuspid Aortic Valve in Infants, Children, and Adolescents: A Review for Primary Care Providers.

1. Talha Niaz, MBBS* 2. Jonathan N. Johnson, MD*,† 3. Frank Cetta, MD*,† 4. Timothy M. Olson, MD*,† 5. Donald J. Hagler, MD*,† 1. *Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, and 2. †Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN * Abbreviations: AHA : : American Heart Association BAV : : bicuspid aortic valve TTE : : transthoracic echocardiography Bicuspid aortic valve is the most common congenital heart defect in children, adolescents, and adults. Primary care providers play an important role in screening, referral, and follow-up of these patients and should be aware of the family screening guidelines, sports participation recommendations, and periodic follow-up requirements for adequate surveillance of the complications that arise from bicuspid aortic valve. After reading this article, readers should be able to: 1. Describe the epidemiology and anatomy of bicuspid aortic valve (BAV). 2. Understand the clinical presentation and diagnosis of BAV in infants, children, and adolescents. 3. Identify the various complications of BAV disease. 4. Discuss the management and follow-up requirements for BAV. 5. Analyze the family screening and sports participation guidelines for patients with BAV. Bicuspid aortic valve (BAV) is the most common congenital heart defect in children, adolescents, and adults. (1) It is a heterogeneous disease that affects both the aortic valve and the aorta. It can lead to many complications, including aortic valve stenosis, regurgitation, or endocarditis. (2)(3) It also can lead to dilation of the aorta, predisposing individuals to a significantly higher risk of aortic aneurysm and dissection. (4) Although most individuals with BAV present with these long-term complications during adulthood, a considerable number of patients may also present during childhood and adolescence with early-onset disease; that may require interventions in up to 12% to 15% of the patients. (5)(6) Therefore, patients with BAV require lifelong follow-up and surveillance. BAV has multiple implications in terms of sports participation and family screening, making it an important subject for primary care providers. This article reviews the anatomy, genetics, presentation, diagnosis, …

Prevalence and characteristics of mitral valve prolapse in military young adults in Taiwan of the CHIEF Heart Study

The prevalence of mitral valve prolapse (MVP) among middle- and older-aged individuals is estimated to be 2–4% in Western countries. However, few studies have been conducted among Asian individuals and young adults. This study included a sample of 2442 consecutive military adults aged 18–39 years in Hualien, Taiwan. MVP was defined as displacement of the anterior or posterior leaflet of the mitral valve to the mid portion of the annular hinge point > 2 mm in the parasternal long-axis view of echocardiography. Cardiac chamber size and wall thickness were measured based on the latest criteria of the American Society of Echocardiography. The clinical features of participants with MVP and those without MVP were compared using a two-sample t test, and the cardiac structures were compared using analysis of covariance with adjustment for body surface area (BSA). Eighty-two participants were diagnosed with MVP, and the prevalence was 3.36% in the overall population. Compared with those without MVP, participants with MVP had a lower body mass index (kg/m2) (24.89 ± 3.70 vs. 23.91 ± 3.45, p = 0.02) and higher prevalence of somatic symptoms related to exercise (11.0% vs. 4.9%, p = 0.02) and systolic click in auscultation (18.3% vs. 0.6%, p < 0.01). In addition, participants with MVP had greater left ventricular mass (gm) and smaller right ventricular wall thickness (mm) and dimensions (mm) indexed by BSA than those without MVP (149.12 ± 35.76 vs. 155.38 ± 36.26; 4.66 ± 0.63 vs. 4.40 ± 0.68; 26.57 ± 3.99 vs. 25.41 ± 4.35, respectively, all p-values < 0.01). In conclusion, the prevalence and clinical features of MVP in military young adults in Taiwan were in line with those in Western countries. Whether the novel MVP phenotype found in this study has any pathological meaning needs further investigation.

Evaluation and diagnostic approach for heart murmurs in children

Heart murmurs are common in children. Most of them are innocent murmurs with normal heart anatomy and function, and only a few are pathologic murmurs with congenital heart anomaly or abnormal heart function. However, a heart murmur may be the sole symptom of serious heart disease. Therefore, careful evaluation of heart murmurs for distinguishing pathologic murmurs from innocent murmurs is important. Heart murmurs are described by their intensity, timing in the cardiac cycle, location, transmission, and quality. Murmurs, such as a holosystolic or diastolic murmur, of grade 3 or higher intensity, harsh quality, an abnormal S2, a systolic click, or increased intensity when the patient stands are more likely to be pathologic murmurs. Innocent murmurs are more likely to be systolic murmurs, with soft sounds, short duration, low pitch, and varying intensity with phases of respiration and posture (disappears with standing). Not only auscultation but also physical examination findings are important to evaluate heart murmurs. The gold standard test for the evaluation of any potentially pathologic murmur is echocardiography. For the appropriate use of echocardiography, close physical examination, including auscultation, is essential and requires considerable practice.

TO STUDY THE INCIDENCES OF CARDIAC MANIFESTATION IN THYROID DISORDER (HYPO &amp; HYPER) BOTH IN RURAL AREA OF MALWA REGION

Background: In this study 100 cases of thyroid dysfunction were studied for the cardiovascular manifestations. Out of these, 60 cases were of hypothyroidism and 40 cases were of hyperthyroidism.&#x0D; There was no age bar for inclusion in the study. All of these cases were selected from those attending the Endocrinology OPD in IMCHRC hospital, Indore.&#x0D; Result: Low pulse pressure is the commonest cardiovascular finding in hypothyroidism (68.33%) followed by diastolic hypertension (55%), soft heart murmur (31.66%), sinus bradycardia (30%) and pericardial effusion (20%) Pulse pressure &gt;40 mm of Hg is the commonest finding in hyperthyroidism. Almost all patients of hyperthyroidism have sinus tachycardia.&#x0D; Conclusion: Study of cardiac signs and symptoms in patient with hyperthyroidism revealed 87.5% prevalence of pulse pressure &gt; 40 mm hg, 85% prevalence of loud heart sound, 82.5% cases of sinus tachycardia, 52.5% cases of hyperdynamic precordium, 47.5% cases of ejection systolic murmur, 42.5% cases of prolonged Qt interval, 25% cases of precordial thrill, 47.5% patients with systolic BP&gt;160 mm Hg, 20 5 cases with mid systolic click, 27.5% patients with LVH , 15% cases with ST-T changes, 5% cases with S3 and 10% patients with atrial fibrillation.&#x0D; Keywords: Cardiac, Manifestation, Thyroid, Hyperthyroidism &amp; Hypothyroidism.

Asymptomatic Coarctation of the Aorta in a Middle-Aged Man; The Significance of Physical Examination

Asymptomatic Coarctation of the Aorta in a Middle-Aged Man; The Significance of Physical Examination

Percutaneous Coronary Intervention for Treatment of Paraganglioma With Coronary Vascularization

A 58-year-old man was referred to the cardiology outpatient clinic because of palpitations. Physical examination highlighted the presence of mitral early systolic click. Transthoracic echocardiography showed a retrocardiac mass that was compressing the left atrium and surrounding the pulmonary

Systolic ejection click versus split first heart sound: Are our ears deceiving us?

Bicuspid aortic valve (BAV) disease is associated with potential lifetime complications, but auscultation of a BAV click is commonly missed or mistaken for a benign split first heart sound. Our objective was to determine whether pediatric cardiologists could reliably distinguish between BAV clicks and benign split first heart sounds. Quality evaluation project using de-identified recordings from an outpatient pediatric cardiology clinic. Twenty-one cardiologists listened to five de-identified recordings of pediatric heart sounds (three with BAV clicks, two with mitral components of benign split first heart sounds) and indicated whether they believed each recording was a BAV or split first heart sound. The accuracy of diagnoses was determined using percent agreement and calculated kappa coefficients for the cohort and subgroups based on those with less than 10 years of experience versus those with ≥10 years. To assess precision, a kappa extension was used for multiple raters to assess interrater agreement. Among participants, diagnostic accuracy of BAV click was 38%, while accuracy of split first heart sound was 41%. No participant correctly diagnosed all sounds. No difference in agreement was observed when stratifying by experience. Kappa was -0.11 (CI 95% -0.31 to 0.08) for all raters, -0.03 (CI 95% -0.39 to 0.33) for those with less than 10 years' experience, and -0.15 (CI 95% -0.38 to 0.08) for those with ≥10 years' experience. The kappa statistic among the 21 raters was 0.01 (95% CI -0.03 to 0.04), indicating poor precision among the raters. In this sample of pediatric cardiologists, the diagnostic accuracy of BAV clicks versus split first heart sounds was worse than chance. There was no association between years of experience and diagnostic accuracy. While further study is needed, these data suggest that an echocardiogram may be valuable when either a systolic ejection click or split first heart sound is heard.

The Peter Principle in Cardiovascular Cell Therapy: The Decline of a Theory or the Theory of a Decline.

Controversies in stem cell therapy for cardiovascular regeneration/repair highlight the need to go back to the root of the problem and analyze the reasons for the current ideological stagnation. Technological advancements are often advocated to overcome a scientific stalemate. However, technology does not suffice without a clear physiological understanding of stem cell biology as a component of the general feedback response to injury. This viewpoint opines that endogenous mechanisms of repair are incompletely understood, and more research is needed in humans and experimental models to dissect the role of stem cells in the pathogenesis of cardiovascular diseases. In 1969, Peter and Hull formulated a management principle stating that anything that is used in more challenging applications will finally fail. Examples of medical theories that failed in translation are countless. This phenomenon can be interpreted in 2 opposite ways: (1) something was wrong in the initial judgment or (2) validation and exploitation were misaligned from the original theory. Furthermore, controversies are often unproductive, that is, during the flat stage of postdiscovery S-curve, experts are mainly occupied in defending or attacking the theory, with the result that they are only picking the low-hanging fruit from the science tree. Not surprisingly, a rapid flourishing of new ideas occurs immediately after the disappearance of imposing leaders.1 There is no infallible method to interpret biological phenomena. However, repeated examination remains a key step. The corresponding author reports an episode in the cardiology ward, condensing the cognitive/interactive aspects of medical diagnosis. Having listened to a patient’s heart, my clinical mentor asked the opinion of attending students. As I was uncertain of what to say, he asked again if I was able to hear a systolic click, his words being echoed by assertive expressions of the assistants. I must have got very red in the face, …

Detection of systolic ejection click using time growing neural network

In this paper, we present a novel neural network for classification of short-duration heart sounds: the time growing neural network (TGNN). The input to the network is the spectral power in adjacent frequency bands as computed in time windows of growing length. Children with heart systolic ejection click (SEC) and normal children are the two groups subjected to analysis. The performance of the TGNN is compared to that of a time delay neural network (TDNN) and a multi-layer perceptron (MLP), using training and test datasets of similar sizes with a total of 614 normal and abnormal cardiac cycles. From the test dataset, the classification rate/sensitivity is found to be 97.0%/98.1% for the TGNN, 85.1%/76.4% for the TDNN, and 92.7%/85.7% for the MLP. The results show that the TGNN performs better than do TDNN and MLP when frequency band power is used as classifier input. The performance of TGNN is also found to exhibit better immunity to noise.

4-Dimensional Cardiac Magnetic Resonance in a Patient With Bicuspid Pulmonic Valve: Characterization of Post-Stenotic Flow

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 33-year-old woman was referred to a cardiologist for an early systolic ejection click and grade III/VI mid peaking systolic murmur at the upper left sternal border. An echocardiogram revealed moderate

Early Recognition and Management of Pulmonary Arterial Hypertension: ACase for Profiling

Early Recognition and Management of Pulmonary Arterial Hypertension: ACase for Profiling

Idiopathic Pulmonary Artery Aneurysm

A 45-year-old man was referred to our hospital after a prolonged history of exertional dyspnea. Clinical examination revealed systolic and diastolic heart murmurs without any systolic click in the second right sternal border. Chest x-ray showed pulmonary artery dilation (Figure 1). Multidetector computed tomography showed a huge pulmonary artery aneurysm ≈70 mm in diameter (Figure 2). Transthoracic echocardiography showed a huge aneurysm of the pulmonary artery by 2D echocardiography (Figure 3). There was no significant tricuspid regurgitation in either the 4-chamber view or the short-axis view, and pulmonary regurgitation due to dilatation of pulmonary annulus was …

Orthostatic intolerance and coronary reserve: a matter of a certain gravity

A 74-year-old woman came to our attention complaining of the recent onset of shortness of breath during light physical activity. She reported orthostatic light-headedness, occasional dizziness, and pre-syncope symptoms for a duration of the prior year. The past history included mitral valve prolapse with mild regurgitation, dyslipidemia, and paroxysmal atrial fibrillation. At presentation, the current medications included propafenone, aminosalicylic acid, and simvastatin. A 24-h-ECG demonstrated the presence of polymorphic ventricular premature beats and asymptomatic ST-segment depression. The treadmill exercise test showed limited exercise tolerance, and a significant downward sloping ST-segment depression in leads V4–V6 at the beginning of step 2 of the Bruce protocol. An exercise myocardial perfusion scan was consistent with a reduced coronary reserve of the anterior wall. Upon admission, lying and up-right arterial pressures were 130/80 and 90/50 mmHg, respectively, while a physical examination documented a systolic click and a late systolic murmur. After medications were suspended, a new treadmill exercise test (Fig. 1, left panel) demonstrated orthostatic hypotension [1] with tachycardia upon standing, and a further decline of arterial pressure and heart rate increase during the Bruce stage 1. Exercise was interrupted due to pre-syncope symptoms after 204600 when 88% of the predicted maximal heart rate had been reached, and ST depression (-1.0 mm, V5–V6) observed. Considering the patient’s characteristics, the estimated pre-test probability of a significant coronary stenosis was 20–50% [2, 3]. The positive likelihood ratio of exercise stress test and myocardial perfusion scan for a significant coronary artery disease was about 10[4]. Thus, the patient’s post-test probability of a significant coronary stenosis was in the 70–90% range. A coronary angiography was thus performed, but ruled out a stenosis of the major coronary vessels. In the absence of stenosis, a reduction of coronary reserve may be secondary to functional mechanisms [5], including the originally misdiagnosed orthostatic hypotension. We thus hypothesized a critical decline in coronary blood flow during upright physical activity due to an exercise-induced significant decrease in arterial pressure on a pre-existing orthostatic hypotension background. To test our hypothesis, an exercise bicycle test was performed in the lying posture, a position unlikely to affect arterial pressure. Exercise was interrupted at 703500 because of physical exhaustion (Fig. 1, right panel). Neither a significant reduction in arterial pressure nor ST-segment changes was observed along the exercise-induced heart rate increase. The maximum heart rate systolic pressure product [6], a broad index of cardiovascular function, increased more when exercise was performed in a lying position than during up-right posture, compared to baseline, although the increase in heart rate was lower in the supine than in the standing position (Fig. 1). G. Costantino Medicina Interna II, Ospedale Sacco, Milan, Italy

Aortic Dissection during Diagnostic Aortography

A 30-year-old man presented to our clinic for evaluation of newly diagnosed hypertension. On examination, he had an apical systolic ejection click, a grade 2/6 systolic murmur, and weak femoral pulses. The difference in blood pressure between his arms and legs was 60 mm Hg. Echocardiography revealed coarctation of the aorta and a bicuspid aortic valve with mild stenosis. (See the Supplementary Appendix, available with the full text of this article at NEJM.org, for a chest radiograph showing the consequences of coarctation.) Catheterization through the right femoral artery was performed in preparation for stenting of the coarctation. Contrast material was injected . . .