Venous Hum Research Articles

Identifying pediatric heart murmurs and distinguishing innocent from pathologic using deep learning

ObjectiveTo develop a deep learning algorithm to perform multi-class classification of normal pediatric heart sounds, innocent murmurs, and pathologic murmurs. MethodsWe prospectively enrolled children under age 18 being evaluated by the Division of Pediatric Cardiology. Parents provided consent for a deidentified recording of their child's heart sounds with a digital stethoscope. Innocent murmurs were validated by a pediatric cardiologist and pathologic murmurs were validated by echocardiogram. To augment our collection of normal heart sounds, we utilized a public database of pediatric heart sound recordings (Oliveira, 2022). We propose two novel approaches for this audio classification task. We train a vision transformer on either Markov transition field or Gramian angular field image representations of the frequency spectrum. We benchmark our results against a ResNet-50 CNN trained on spectrogram images. ResultsOur final dataset consisted of 366 normal heart sounds, 175 innocent murmurs, and 216 pathologic murmurs. Innocent murmurs collected include Still's murmur, venous hum, and flow murmurs. Pathologic murmurs included ventricular septal defect, tetralogy of Fallot, aortic regurgitation, aortic stenosis, pulmonary stenosis, mitral regurgitation and stenosis, and tricuspid regurgitation. We find that the Vision Transformer consistently outperforms the ResNet-50 on all three image representations, and that the Gramian angular field is the superior image representation for pediatric heart sounds. We calculated a one-vs-rest multi-class ROC curve for each of the three classes. Our best model achieves an area under the curve (AUC) value of 0.92 ± 0.05, 0.83 ± 0.04, and 0.88 ± 0.04 for identifying normal heart sounds, innocent murmurs, and pathologic murmurs, respectively. ConclusionWe present two novel methods for pediatric heart sound classification, which outperforms the current standard of using a convolutional neural network trained on spectrogram images. To our knowledge, we are the first to demonstrate multi-class classification of pediatric murmurs. Multiclass output affords a more explainable and interpretable model, which can facilitate further model improvement in the downstream model development cycle and enhance clinician trust and therefore adoption.

Courveilhier Baumgarten Syndrome: A Rare Case Report

A 44 year old female had presented with history of abdominal distension of 20 days duration and on examination he had prominent abdominal vein and a venous hum with Ascites. He had no history of altered sensorium, melena. The clinical scenario was suggestive of Cruveilhier Baumgarten syndrome

S2622 Cruveilhier- Baumgarten Syndrome

Introduction: Cruveilhier- Baumgarten syndrome CB) is an uncommon condition, the term is used for cases of liver cirrhosis with portal hypertension in which a recanalization of umbilical and paraumbilical veins causes a loud venous hum that can be heard over the abdomen. Case Description/Methods: A 51 year old male with a past medical history of alcohol abuse, alcoholic liver cirrhosis and esophageal varices presented to the emergency room complaining of coffee ground emesis and dark-colored stools. On a physical exam, a small umbilical venous dilatation with a low-pitched continuous hum was noted on auscultation. Abdominal ultrasound demonstrated hepatofugal flow. CT abdomen and pelvis without contrast showed findings consistent with cirrhotic liver, mild ascites, splenomegaly and umbilical vein recanalization. The patient underwent an EGD, which was negative for any esophageal or gastric varices. Discussion: In 1833 Pegot reported a case of portal hypertension in which a loud venous hum was heard at the umbilicus. In 1883, Sappey described accessory portal veins in the suspensory ligament entering the liver capsule through different locations, such as the vessels located at the falciform ligament through which the anterior parietal veins communicate with the left branch of the portal vein. These vessels play an important role in the origin of transhepatic portosystemic shunts. Paraumbilical vessels may anastomose with the superior epigastric or internal thoracic veins and drain into the superior vena cava or anastomose with the inferior epigastric vein and then drain into the IVC through the external iliac vein. In CB syndrome, the umbilical portion of the left portal vein feeds the paraumbilical vein that then leaves the liver and extends toward the umbilicus. Our case describes a patient with liver cirrhosis who was found to have a continuous umbilical venous hum on a physical exam with imaging findings consistent with a recanalized paraumbilical vein. It is hypothesized that the recanalization of the paraumbilical vein in portal hypertension acts to decrease hepatofugal flow, thus becoming a preventative factor in the formation of esophageal varices. Although uncommon, the presence of recanalization of the paraumbilical vein implies a variation in the prognosis in those with decompensated liver cirrhosis, thus, warrants further investigation. We presented a case of CB syndrome, a condition in which a transhepatic portosystemic shunt can prevent the formation of esophageal varices.

Initial Field Test of a Cloud-Based Cardiac Auscultation System to Determine Murmur Etiology in Rural China.

A system for collection, distribution, and long distant, asynchronous interpretation of cardiac auscultation has been developed and field-tested in rural China. We initiated a proof-of-concept test as a critical component of design of a system to allow rural physicians with little experience in evaluation of congenital heart disease (CHD) to obtain assistance in diagnosis and management of children with significant heart disease. The project tested the hypothesis that acceptable screening of heart murmurs could be accomplished using a digital stethoscope and internet cloud transmittal to deliver phonocardiograms to an experienced observer. Of the 7993 children who underwent school-based screening in the Menghai District of Yunnan Province, Peoples Republic of China, 149 had a murmur noted by a screener. They had digital heart sounds and phonocardiograms collected with the HeartLink tele auscultation system, and underwent echocardiography by a cardiology resident from the First Affiliated Hospital of Kunming Medical University. The digital phonocardiograms, stored on a cloud server, were later remotely reviewed by a board-certified American pediatric cardiologist. Fourteen of these subjects were found to have CHD confirmed by echocardiogram. Using the HeartLink system, the pediatric cardiologist identified 11 of the 14 subjects with pathological murmurs, and missed three subjects with atrial septal defects, which were incorrectly identified as venous hum or Still's murmur. In addition, ten subjects were recorded as having pathological murmurs, when no CHD was confirmed by echocardiography during the field study. The overall test accuracy was 91% with 78.5% sensitivity and 92.6% specificity. This proof-of-concept study demonstrated the feasibility of differentiating pathologic murmurs due to CHD from normal functional heart murmurs with the HeartLink system. This field study is an initial step to develop a cost-effective CHD screening strategy in low-resource settings with a shortage of trained medical professionals and pediatric heart programs.

Accidental Heart Murmurs

Introduction:Accidental murmurs occur in anatomically and physiologically normal heart. Accidental (innocent) murmurs have their own clearly defined clinical characteristics (asymptomatic, they require minimal follow-up care).Aim:To point out the significance of auscultation of the heart in the differentiation of heart murmurs and show clinical characteristics of accidental heart murmurs.Material and methods:Article presents review of literature which deals with the issue of accidental heart murmurs in the pediatric cardiology.Results:In the group of accidental murmurs we include classic vibratory parasternal-precordial Stills murmur, pulmonary ejection murmur, the systolic murmur of pulmonary flow in neonates, venous hum, carotid bruit, Potaine murmur, benign cephalic murmur and mammary souffle.Conclusion:Accidental heart murmurs are revealed by auscultation in over 50% of children and youth, with a peak occurrence between 3-6 years or 8-12 years of life. Reducing the frequency of murmurs in the later period can be related to poor conduction of the murmur, although the disappearance of murmur in principle is not expected. It is the most common reason of cardiac treatment of the child, and is a common cause of unreasonable concern of parents.

CLINICAL PROFILE OF PATIENTS PRESENTING WITH ANEMIA IN A TERTIARY CARE RURAL HOSPITAL OF WESTERN MAHARASHTRA

Background: Anemia is defined as reduction of the total red cell mass below normal limits. Anemia is usually diagnosed based on a reduction in the haematocrit (the ratio of packed red cells to the blood volume) and the hemoglobin concentration of the blood to levels that are below the normal range. Dermal loss of iron is also suggested as one of the possible contributing factors in the genesis of iron deficiency Anemia in the tropics. In view of the geographical location of western Maharashtra which too has climate similar to tropical parts it was thought prudent to evaluate the clinical profile of anemia in the rural patients presenting with the manifestations of anemia. Objectives: To study Clinical profile, nail changes and type of anemia on Peripheral blood picture of patients presenting with Anemia in a tertiary care rural hospital of Western Maharashtra. Methodology: Total 200 Patients diagnosed to be cases of anemia in a tertiary care rural hospital of Western Maharashtra were enrolled for the study during the study period. All the patients satisfying the above inclusion and exclusion criteria were studied for Clinical profile, nail changes and type of anemia on Peripheral blood picture. Results: In this study out of 200 cases the maximum no of cases seen in >40 yrs were 128(64%). The most frequent symptom was easy fatigability which was present in 190(80%) of patients followed by breathlessness in 132(76%) and the signs noted were Pallor in 188(94%), Venous hum in 88(44%), Pedal edema in 80(40%), signs of Heart failure in 80(40%). The most common type of anemia seen of Peripheral blood smear was Microcytic hypochromic in 84(42%) followed by Dimorphic in 54(27%). The proportion of Platonychia is highly significant than Koilonychias in all types of anemia. Conclusion: The clinical profile of anemia studied in the patients coming to the tertiary care hospital in rural western revealed similar pattern of presentation with other studies with easy fatigability and breathlessness as most common symptoms and pallor as most common sign . The Peripheral blood smears revealed Microcytic hypochromic anemia in 44% patient as most common morphological anemia with Platonychia as most common nail changes in all types of morphological anemia. Keywords: Anemia, Clinical profile, Peripheral Blood Smear , Microcytic Hypochromic, Koilonychias, Platonychia

Adductor Muscle Echinococcosis: A Rare Presentation

Hydatid cyst disease caused by Echinococcus granulosus may at times affect unusual sites and present a diagnostic challenge especially if found at rare locations. A 51 year male presented with a slowly progressive swelling in the upper medial aspect of the left thigh without pain and any discharge. There was no history of trauma and any dog keeping. Examination revealed a large 10 × 12 cm soft tissue swelling which was non-tender, non-pulsatile, without any features of acute inflammation figure 1. Overlying skin was normal. No bruit or venous hum was heard.

Abstract 19011: Initial Field Testing of a Cloud-based Cardiac Auscultation Information Management System in Rural Southwest Kunming Province, Peoples Republic of China

Introduction: Auscultation (Ausc) is used around the world to screen for congenital heart disease (CHD). We describe initial field testing of a cloud-based Ausc information management system in rural China school children with limited access to cardiac care . Our goal is to develop an economical system to facilitate access to cardiac care for underserved children in low- and middle-income countries. Hypothesis: Web/cloud based distant transmission of auscultation exam can facilitate screening for congenital heart disease. Methods: A team of cardiology staff from a tertiary hospital conducted field screening for CHD) in rural school children in Yunnan Province, People’s Republic of China. Each child with a murmur with traditional Ausc underwent echo screening and digital Ausc (Thinklabs, USA). Heart sounds were collected from 5 positions (URSB, ULSB, LLSB, apex and mid-LSB), and uploaded to a server using a tablet application (HeartLink System, USA). Blinded Ausc 3-5 months later was compared with echo finding at on-site screening. Results: 8000 children were screened with standard Ausc over 4 days by a team from Kunming Medical University and First University Hospital. Heart sounds were recorded for 149 subjects. The best vibratory quality of an innocent Still murmur was heard at LLSB in 52,at mid-LSB in 51, apex in 10 and URSB/ULSB in 4. Digital Ausc found pathologic murmurs in 11 of 14 subjects with echo-diagnosed CHD. Three missed were ASD called venous hum in 2 of 3; likely related to respiratory artifact at the URSB/ULSB. Accuracy was 136/149 or 91% with 10 false positive. Positive predictive value 52% and negative predictive value 98%. The graphical phonocardiogram facilitates visual analysis of S2 splitting and the duration and timing of the cardiac murmur. Conclusions: The cloud-based digital Ausc system is able to collect, transmit, organize and display phonocardiograms for remote CHD screening and consultation. Difficulty with respiratory contamination of the signal is noted. VSD and Still murmur were successfully differentiated. The visual phonocardiographic display can aid S2 analysis for splitting. The pilot study demonstrates the potential use of this system to extend pediatric cardiology expertise to underserved rural areas around the world.

Single-center 10-year experience in treating patients with vascular tinnitus: diagnostic approaches and treatment outcomes.

ObjectivesVascular tinnitus is the most common form of pulsatile tinnitus, particularly when the tinnitus corresponds with the pulse of patients. In this study, we reviewed the 10-year clinical data on vascular tinnitus of our tinnitus clinic to investigate the frequency of the underlying etiologies, to introduce a diagnostic protocol, and to evaluate the treatment outcomes.MethodsWe retrospectively collected the data of 57 patients who were diagnosed as vascular tinnitus between April 2001 and December 2011. Careful history taking, otoscopy, thorough physical examinations, audiometry, laboratory tests, as well as radiologic examinations were performed according to our diagnostic protocol to find the origin of pulsatile tinnitus. Treatment options were individualized based on the specific etiology, and the outcomes were assessed using patient's subjective reports at the follow-up interviews.ResultsHigh jugular bulb was the most common cause (47.4%) of vascular tinnitus, and venous hum was the next (17.5%). Dural arteriovenous fistula, intracranial aneurysm, atherosclerotic carotid artery disease, and hypertension were less common causes. Vascular tinnitus was alleviated in most patients after the appropriate treatment: surgical intervention, tinnitus retraining therapy, reassurance, and medications.ConclusionVascular tinnitus can be successfully diagnosed by the regular use of the suggested protocol. Many patients with vascular tinnitus have treatable underlying etiologies. Treatment of those etiologies or at least counseling about the tinnitus itself can benefit the patients with troublesome vascular tinnitus.

Inflammatory myofibroblastic tumor of the temporal bone presenting with pulsatile tinnitus: a case report

IntroductionInflammatory myofibroblastic tumor of the temporal bone is an unusual but distinct disease entity. The most common presenting symptoms are otalgia, otorrhea, hearing loss, facial palsy, and vertigo. We describe here what we believe to be the first reported case of a patient presenting with persistent pulsatile tinnitus. The clinical features, radiological and histopathologic findings, and treatment outcomes of the patient are presented.Case presentationA 59-year-old woman of Chinese Han origin presented with complaints of left-sided pulsatile tinnitus and progressive hearing loss for several years. Clinical evaluations revealed a reddish mass behind the intact tympanic membrane, and a moderately severe conductive hearing loss in the left ear. The computed tomographic imaging of the temporal bone demonstrated a slightly ill-defined left middle ear soft tissue mass involving the posterior portion of the mesotympanum and epitympanum, and the mastoid antrum. The patient underwent surgical excision of the lesion which subsequently resolved her symptoms. Postoperative pathology was consistent with an inflammatory myofibroblastic tumor.ConclusionsAn inflammatory myofibroblastic tumor of the temporal bone can present clinically with pulsatile tinnitus and masquerade as venous hum or vascular tumors of the middle ear; therefore, it should be included in the differential diagnosis of pulsatile tinnitus.

Citizen Monsters: Race and Cannibalism in Suzette Mayr’s Venous Hum

Halfway through Suzette Mayr’s 2004 novel Venous Hum, a number of the central characters are revealed to be cannibalistic vampires, some of whom are reformed and loveable while others are violent and villainous. The novel is funny and satirical with connections to cult horror films and canonical Canadian literature. By reading Venous Hum in terms of magic realism and literary cannibalism, this essay focusses on the ways in which Mayr’s evocations of vampires and cannibals lead readers towards a politicized questioning of the relationship between perceived differences and official nation-state discourse. This essay thus examines the novel’s magic realist monster imagery in relation to racialization and the politics of interpellation, visibility, inclusion, and assimilation in multicultural Canada. Mayr makes ironic use of the colonial resonances of cannibalistic discourse in order to critique the relationship between the nation-state and its varied citizens, and between official multicultural policy and the lived experience of racialization.

Management of Venous Pulsatile Tinnitus

Objective: To discuss the therapeutic effect of ligation of the internal jugular vein and how to deal with pulsatile tinnitus of venous origin. Method: A retrospective study was conducted on 12 patients who were diagnosed with venous hum and treated with ligation of the jugular vein. They all had normal otoscopy findings. Results: These 12 patients were all women, ranging in age from 27 to 61 years. Seven patients got relief of tinnitus right after the surgery, among which 5 patient’s symptoms recurred within 2 years. The rest got no relief and 1 of them aggravated into intolerable roaring. Conclusion: Diagnosis of venous hum should be made only after careful elimination of other disorders, such as BIH, ACAD, HJB, and other rare vascular anomalies. Ligation of IJV should be avoided even for the treatment of venous hum because of the poor effect and unpredictable complications.

Vise Location of the Vertical Vein in a Neonate With a Supracardiac Total Anomalous Pulmonary Venous Connection

A newborn delivered at 37 weeks of gestation with a birth weight of 2,526 g was transferred to our hospital because of respiratory distress and cyanosis. The neonate had a heart rate of 140 beats/min and a respiratory rate of 50 breaths/min. The oxygen saturation was 75%. At auscultation, the pulmonary second heart sound was accentuated, and venous hum was noted in the second intercostal space of the left sternal border. Hepatomegaly also was noted. A chest X-ray showed a cardiothoracic ratio of 58%, with increased pulmonary congestion (Fig. 1). Echocardiography showed that the right heart was markedly enlarged and that all the pulmonary veins joined behind the left atrium connected to the innominate vein via the vertical vein, consistent with a supracardiac total anomalous pulmonary venous connection (TAPVC). Doppler imaging showed that the flow velocity was increased at the vertical vein. An atrial septal defect with right-to-left shunting and a large patent ductus arteriosus with a bidirectional shunt also were shown. Multidetector computed tomography (MDCT) (64 detectors) performed on the second day of age showed the horizontal common pulmonary vein draining to the left innominate vein via the vertical vein. The vertical vein ascended anteriorly to the left pulmonary artery and posteriorly to the ductus arteriosus and left bronchus, which was externally compressed by the ductus rather than the left bronchus (Figs. 2, 3). On the third day of age, we performed surgical correction using a cardiopulmonary bypass. The course of the vertical vein is vital with regard to obstruction in patients with supracardiac TAPVC. Usually, the vertical vein ascends anteriorly to the left pulmonary artery and the left bronchus, which is not obstructed. However, it may be obstructed when it passes between the left bronchus posteriorly and the left pulmonary artery anteriorly, the so-called ‘‘vise location’’ [1, 2]. Recent imaging methods such as MDCT and magnetic resonance angiography are useful for preoperative patients with TAPVC. Because echocardiography has a limited field of view for assessing peripheral pulmonary veins, we prefer MDCT for preoperative imaging, which requires less time for image acquisition [3]. In the current case, MDCT

Reunion: an Albertan Revenge Comedy

This essay looks critically at binary stereotypes that are challenged and upended in Suzette Mayr’s novel, Venous Hum, as well as other texts. By citing this novel, the essay critiques the figure of the monster as a hybrid who threatens notions of stable identity through enacting a metaphor of embodied miscegenation. This essay investigates the role of the monster as intrepid hero in the state of constant transition, one who crosses the us/them divide, who represents immigrant, and racialized character, and defiant sexuality, and beautiful deviant. Through an examination of “Alberta” stereotypes, the essay explicates a “universal” binary and challenges homogenizing narratives about the Canadian prairies. In the novel under discussion, the trope of the high school reunion acts as pivot for hurtful past narratives (both in the book and in Alberta’s past), and serves as climax for a book wherein so many characters claim the role of “monster” that the very definitions of insider/outsider ceases to mark the border between “normal” and “abnormal.”

Venous Hum Tinnitus

Venous hum tinnitus is an uncommon but treatable cause of objective tinnitus. Ligation of the internal jugular vein has been described with favorable results when the tinnitus is loud enough to disturb sleep or hearing. Careful history and physical examination is helpful in establishing the diagnosis, but other causes should be excluded prior to ligation. Angiography is indicated to rule out other anomalies and establish patency of the contralateral jugular vein. We describe two cases of venous hum tinnitus treated by ligation of the jugular vein.

Cervical Aortic Arch with a New Twist

We report a case of cervical aortic arch (CAA) with unusual tortuosity in the mid thoracic descending aorta. The presentation of this case involving a 6-year-old girl with CAA reinforces clinical clues and associations. She was referred for catheterization to evaluate prominent right sided neck pulsations attributed to mild coarctation of the aorta with inability to image a normal aorta on an echocardiogram. At examination, the girl had intermittent arm–leg blood pressure discrepancies (e.g., right arm, 115/76; right leg, 98/67). When sitting, she had hyperdynamic neck pulsations in the right neck and a continuous murmur louder than a typical venous hum. Her small stature, dysmorphic features, and hypernasal speech were not shared by her twin brother. Chest X-ray did not confirm arch laterality or rib notching. Probable abnormal aortic arch development was diagnosed, and suspicion of velocardiofacial syndrome was supported with genetic testing, which confirmed 22q11 deletion. At catheterization, a patent foramen ovale facilitated catheter entry into the left ventricle. After left ventricular injection, the elongated ascending aorta with the right aortic arch and cervical extent plus the characteristic origin of the arch vessels was identified (Figs.1 and 2) [3]. Unique to this case was the ‘‘twist’’ seen in the mid thoracic descending aorta to the right of the spine before the aorta took a retroesophageal course and crossed to descend on the left. There was a mild gradient between the left ventricle (112/0, 10) and femoral artery (100/70; mean, 98). However, no discrete area of obstruction in the course of the aorta was identified. The congenital anomaly of CAA characterized by the cervical extent of the aortic arch with the apex positioned in the neck above the clavicle was first reported in 1914. Approximately 150 cases have been reported to date [1–3]. One proposal is that CAA develops during weeks 4 to 6 of fetal life from abnormal persistence of the third arch with involution of the left fourth arch, which locates the aortic arch to a more cervical position. This explanation also allows for the expected separate origins of the carotid arteries. There is no true innominate artery, and the last vessel off the aorta is the subclavian artery arising from the descending aorta contralateral to the arch. This is the pattern of CAA identified in patients with 22q11.2 deletion [1]. Clinically unifying to the diagnosis of the cervical aortic arch is the recognition of prominent pulsations in the neck and a cardiac murmur. Our patient should be followed for symptoms of vascular ring, aortic arch obstruction, aortic aneurysm, and anticipation of problems related to her confirmed 22q11.2 deletion. The unusual tortuosity of the aorta may be a new finding in the CAA complex.

Venous Hum Causing Tinnitus: Case Report and Review of the Literature

Hearing one's own heart murmur has been reported in adults, but has not been reported in the pediatric literature. This study reports the case of a young child who clearly heard her own venous hum, causing her to complain of pulsatile tinnitus. This entity should be included in the differential diagnosis of pulsatile tinnitus and by doing so pediatricians and cardiologists may avoid ordering unnecessary diagnostic procedures.

Vena cava inferior thrombosis detected by venous hum: a case report

We describe a patient in which a venous hum, heard during abdominal auscultation, lead to the diagnosis of a vena cava inferior thrombosis.

Endoscopic Doppler US probe for the diagnosis of gastric varices (with videos)

Gastric varices may appear similar to enlarged gastric folds and submucosal neoplasms at endoscopy. A simple endoscopic method to diagnose variceal blood flow without formal EUS could be clinically useful. To demonstrate the use of Doppler US (DOP-US) in the diagnosis of gastric varices. Case series. A tertiary-care U.S. academic medical center. Eight patients with findings of gastric submucosal lesions of uncertain etiology on EGD. EGD with DOP-US examination, with or without standard EUS. Presence or absence of audible DOP-US signal and EUS findings for gastric submucosal lesions. DOP-US demonstrated a reproducible continuous venous hum in 5 cases of gastric varices (confirmed by EUS in 2 cases). A sixth case of gastric varices demonstrated pulsatile flow with DOP-US (confirmed by EUS). In 1 case of a GI stromal tumor (GIST) in the stomach, no signal was heard when the lesion itself was examined by DOP-US. In a final case of Menetrier's disease, no signal was heard when the giant gastric folds were examined. DOP-US can help differentiate gastric varices from other gastric submucosal lesions. The use of DOP-US may obviate the need for EUS to confirm gastric varices when the EGD diagnosis is uncertain.

External jugular venous aneurysm: an unusual cause of a neck mass in a young child 1,2

AN 18-MONTH-old girl was referred for an asymptomatic left neck mass that was noted at 6 months of age. The mass was soft, bluish, and located in the left supraclavicular area. It was barely visible at rest but became more prominent with crying (Fig 1). There was no pulsation over the mass or venous hum that could be heard. The mass had been increasing gradually in size with time. No other abnormalities were noted.