The role of auscultation in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact ventricular septum and right-to-left interatrial shunt

A clinical and phonocardiographic study has been made of the murmurs and heart sounds in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact septum and right-to-left interatrial shunt. A striking difference in the behaviour of the systolic murmur was found in the two conditions and this affords a new, simple bedside method of diagnosis. Important differences in the behaviour of the heart sounds were also found, but these are usually more difficult to evaluate clinically and may require special study.

Native valve endocarditis with aorta-to-left atrial fistula due to Corynebacterium amycolatum

Infective endocarditis remains a pathology with a high rate of complications and mortality. One of the most dramatic complications is abscess formation. A rare evolution of abscess formation is the development of fistula. We describe an 88-year-old woman with an aortic root abscess and aorta-to-left atrial fistula. To our knowledge this has only been described with streptococcus species as causative micro-organism. In this case the abscess was caused by Corynebacterium amycolatum, which is an infrequently found micro-organism.

Incidence and clinical features of asymptomatic atrial septal defect in school children diagnosed by heart disease screening

The purpose of this study was to investigate the incidence and clinical features of atrial septal defect (ASD) in school children in Japan who were diagnosed by heart disease screening. From 1989 to 1998, a questionnaire, electrocardiography (ECG) and phonocardiogram were obtained from school children when they entered their first year of elementary school (n=86,142) or junior high school (n=80,632). In this program, 33 asymptomatic ASD patients were newly diagnosed (0.020%). The ECG findings showed incomplete right bundle-branch block (79%), right axis deviation (55%), and right ventricular hypertrophy (9%). An ejection systolic murmur was audible in 30 patients (94%) and mid-diastolic murmur in 10 patients (30%). Thirty patients (90%) showed fixed split of second heart sound. Using echocardiography or catheter observation, 31 patients (94%) were judged to require closure of the ASD. Although the medical care is widely available in Japan, undetected ASD patients were not rare and importantly, most of them required closure of the defect even if they were asymptomatic.

Main pulmonary artery stenosis caused by fibrocalcified mass in a young infant

We present a rare case of main pulmonary artery stenosis secondary to protruding fibrous material in the main pulmonary artery associated with patent ductus arteriosus. A 1-month-old baby boy manifested cardiac murmur. Echocardiogram showed circumferential high echogenic mass inside the main pulmonary artery with pressure gradient of 49 mmHg and patent ductus arteriosus. The mass did not regress during 3 months' follow-up period. Angiographic images showed that the circular filling defect was located at the main pulmonary artery distal to pulmonary valve, and pulmonary valve and both pulmonary arteries were normal. After surgical removal of the circumferential material and ductus ligation, the pressure gradient became negligible. The material was consisted of scarcely cellular fibrous tissue, abundant coagulum of fibrinous material and dense calcification.

Parental anxiety associated with referral of a child to a pediatric cardiologist for evaluation of a Still's murmur

OBJECTIVE

We assessed factors contributing to parental anxiety when children are referred to a cardiology clinic for evaluation of a Still's murmur.

METHODS

Parents of 95 children completed questionnaires designed to assess family and patient characteristics, parents' ratings of their anxiety and the reassurance they received from their pediatrician, and current (state) and general anxiety levels.

RESULTS

Parents reported anxiety about multiple issues including the need for medication (49%), sports restrictions (41%), cardiac surgery (29%), cardiac risk for siblings (20%), and premature death (13%). Of reporting mothers, 19% felt the murmur resulted from something they did wrong during pregnancy. Although 54% of parents were extremely reassured by their pediatrician, only 17% had no anxiety associated with the specialty visit. After reassurance from the cardiologist, 7% of parents had persistent anxiety. In multivariable analysis, 2 features, both related to the referring pediatrician, were significantly related to parental anxiety level. High parental anxiety was associated with lower pediatrician reassurance ratings and greater pediatrician practice years.

CONCLUSIONS

Parental anxiety is common among parents of children referred for specialty evaluation. Educational strategies to improve pediatrician communication skills with parents may improve quality of care.

Automated cardiac auscultation for detection of pathologic heart murmurs

Experienced cardiologists can usually recognize pathologic heart murmurs with high sensitivity and specificity, although nonspecialists with less clinical experience may have more difficulty. Harsh, pansystolic murmurs of intensity grade > or = 3 at the left upper sternal border (LUSB) are likely to be associated with pathology. In this study, we designed a system for automatically detecting systolic murmurs due to a variety of conditions and examined the correlation between relative murmur intensity and likelihood of pathology. Cardiac auscultatory examinations of 194 children and young adults were recorded, digitized, and stored along with corresponding echocardiographic diagnoses, and automated spectral analysis using continuous wavelet transforms was performed. Patients without heart disease and either no murmur or an innocent murmur (n = 95) were compared to patients with a variety of cardiac diagnoses and a pathologic systolic murmur present at the LUSB (n = 99). The sensitivity and specificity of the automated system for detecting pathologic murmurs with intensity grade > or = 2 were both 96%, and for grade > or = 3 murmurs they were 100%. Automated cardiac auscultation and interpretation may be useful as a diagnostic aid to support clinical decision making.

An uncommon echocardiographic marker for anomalous origin of the left coronary artery from the pulmonary artery: visualization of intercoronary collaterals within the ventricular septum

A rare and striking echocardiographic finding with color-flow Doppler--visualization of intercoronary collaterals within the ventricular septum--in an asymptomatic 5-year-old girl is reported. It strongly suggests anomalous origin of the left coronary artery from the pulmonary artery. Several additional echocardiographic features can secure the diagnosis and allow one to proceed with surgical correction without confirmatory cardiac catheterization and angiocardiography. The ages of our patient and of the seven cases reported previously suggest that these collaterals will more likely be identified beyond infancy and in relatively asymptomatic patients with this congenital anomaly.

Evaluating cardiac murmurs; are diagnostic tests helpful?

The detection of an asymptomatic murmur in a child usually results in a referral to a consultant paediatrician. In most cases a chest radiograph (CXR) and electrocardiograph (ECG) are performed as an aid to diagnosis, however the evidence for this is contradictory. A retrospective chart review of children referred with asymptomatic cardiac murmurs in a one-year period was conducted. We wished to determine whether CXR and ECG are useful diagnostic aids. 81 patient charts were reviewed. Of those patients with a clinical diagnosis of pathological murmur all had normal CXR and ECG. Never the less 2 cases were referred for echocardiogram and were found to have structural heart disease. Of those with a clinical diagnosis of innocent murmur most (81%) had a CXR and ECG and in most cases (96%) these were normal. Those cases with abnormal investigations subsequently were shown to have structurally normal hearts on echocardiogram. We conclude that routine use of CXR and ECG in evaluating asymptomatic cardiac murmurs in children is not useful.

Failure of medicine: evolution of an atrial septal defect to an Eisenmenger syndrome

The atrial septal defect (ASD) is the most commonly diagnosed congenital defect in adults and has a prevalence of 7.5% of all congenital cardiac anomalies. Less invasive imaging techniques, especially transthoracic and transoesophageal echocardiography, provide more accurate diagnostics, resulting in earlier diagnosis and treatment. Despite these opportunities in high-tech countries, medicine may still fail in detecting initially correctable cardiac anomalies. We present a case of 41-year-old woman with an abnormal murmur at childhood that disappeared with time due to the development of an Eisenmenger syndrome. The importance of a complete haemodynamic evaluation in this patient is illustrated.

Observations on the mechanism of atrial gallop rhythm

An atrial gallop sound is a frequent finding in hypertensive cardiovascular disease, myocardial infarction, and in the presence of a prolonged atrioventricular conduction time. In view of evidence relating this sound to a ventricular pressure wave resulting from atrial contraction, modification of this hemodynamic event was studied by means of tourniquet pooling of blood in the extremities. In the 18 patients studied, this maneuver caused striking changes in the intensity and timing of the atrial gallop. Analysis of these changes helps explain the frequent appearance of this triple rhythm in severe hypertensive cardiovascular disease.

The forces needed to evoke sounds from cardiac tissues, and the attenuation of heart sounds

There has been no study of the efficiency of any sound-producing system. Here there is a description of a device that records the force of each pull applied to a valve segment or strip of myocardium while the sound evoked is recorded. The relation of force to sound intensity, and the attenuation of sounds in air, blood, and ventricular and chest walls provide some quantitative data on a neglected phase of cardiac physiology.