Mid-systolic click and mitral valve prolapse following mitral commissurotomy.

Five patients with rheumatic mitral stenosis were observed to have mid-systolic clicks with murmurs of mitral regurgitation at various intervals after mitral commissurotomy. In two patients echocardiography showed an unusually rapid posterior deflection of the mitral valve coinciding exactly with a systolic nonejection click. It is speculated that the shortened, fused chordae tendineae, compromised by mitral commissurotomy, rigidly hold the valve leaflets fixed at the onset of systole. During systole, ventricular conformational changes, in the face of marginal coaptation of thickened and fibrotic mitral leaflets, allow the mitral valve to be forced abruptly towards the left atrium with great velocity. This is manifested by a loud systolic click and, in some patients, a near vertical posterior systolic deflection of the mitral valve on the echocardiogram. The systolic click may occur without echocardiographic or angiographic evidence of mitral valve prolapse. Unusually loud mid-systolic clicks can be heard in patients with rheumatic heart disease after mitral commissurotomy and may be accompanied by a distinctive echocardiographic appearance of the mitral valve.

Group teaching of auscultation. Use of a new wireless stethoscope-type headphone.

A new technique using infrared light for the transmission of heart sounds and murmurs is described. This method enables the simultaneous transmission of heart sounds and murmurs to large groups of persons without the need for hard-wire connections to the amplifying device. The method facilitates teaching of cardiac auscultation at the bedside as well as in the setting of conferences, seminars or postgraduate education programs.

Development and progression of aortic valve stenosis: atherosclerosis risk factors--a causal relationship? A clinical morphologic study.

Hospital records of 120 patients undergoing aortic valve replacement were retrospectively reviewed for risk factors associated with early aortic valve replacement. Patients were separated into four groups (rheumatic, congenital bicuspid, degenerative, and miscellaneous) based upon the morphologic etiology of aortic stenosis. Multiple regression analysis was performed using age at surgery as the dependent variable. Independent variables for the study were race, gender, systemic hypertension, total triglyceride level, total serum cholesterol level, tobacco smoking history, diabetes mellitus, and angiographic coronary artery disease. In the rheumatic valve group only race showed a statistically significant risk effect whereas in the congenital bicuspid valve group race, gender, and triglycerides were statistically correlated with age at surgery. In the degenerative valve group gender and smoking were found to be statistically significant risk factors. The establishment of aortic stenosis risk factors might be an indication for clinical trials of risk factor modification in patients with aortic stenosis.

Cardiac pearls.

Most diagnoses of cardiovascular disease are made in the office or at the bedside. For example, in pulsus alternans of the radial pulse, observed when first greeting a patient, alteration of intensity of the second sound and systolic murmur and a ventricular (S3) gallop are clinical pearls--often subtle--that diagnose cardiac decompensation. A faint gallop, ventricular (S3) or atrial (S4), might be overlooked in a patient who has an emphysematous chest and an increase in anteroposterior diameter if one listens over the usual areas of the precordium. However, the gallop might be detected easily by listening over the xiphoid or epigastric area. How do you tell the difference between an S4, a split first sound, and an ejection sound? The S4 is eliminated with pressure on the stethoscope, but pressure does not eliminate the ejection sound or the splitting of S1. The atrial sound (S4) is most frequently found in patients who have coronary heart disease, and it is a constant finding in patients who have hypertension. It does not denote heart failure, as does the S3 (ventricular) gallop. In some patients, both atrial (S4) and ventricular (S3) diastolic gallops may be present. This occurrence is common in patients with cardiac decompensation associated with coronary heart disease, hypertensive heart disease, and dilated cardiomyopathy. When these diastolic filling sounds occur in close proximity, a short rumbling murmur may be heard, which causes confusion of this sound with that of a valvular or congenital lesion. When both sounds occur exactly simultaneously, a single sound results. Often, this sound is louder than either the first or second sound and can be misinterpreted as either a valvular or congenital lesion. This, however, is a summation gallop, which is rare. For the most accurate timing of heart sounds and murmurs, the simple technique called "inching" is the best. Keeping the second sound in mind as a reference, the physician moves (inches) the stethoscope from the aortic area to the apex. An extra sound may be noted to occur in systole before the second sound, thereby diagnosing a systolic click. If the sound occurs after the second sound, however, it is an S3 or ventricular diastolic gallop. If a murmur appears before S2, it is a systolic murmur; if it appears after S2, it is a diastolic murmur. When the Austin-Flint murmur is heard, significant aortic regurgitation exists.(ABSTRACT TRUNCATED AT 400 WORDS)