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Electrical and Mechanical Alternation in Pericardial Effusion
341
Electrical and Mechanical Alternation in Pericardial Effusion *
c:
H
George E. Gabor, M.D., Fred Winsberg, M.D., and Henry S. Bloom, M.D.
In a case of traumatic pericardial effusion with electrical and mechanical alternation, ultrasonic cardiography demonstrated excessive oscillatory motion of the heart. This motion occurred in both anteroposterior and left-to-right directions. The frequency of the motion was half the pulse rate and thus readily explains the electrical alternation. Pericardiocentesis abolished both of these phenomena.
r I
,I
E
lectrical alternation in patients with massive pericardia! effusion has been attributed to the fact that the heart changes in position with alternate beats when suspended in a large, fluid-filled pericardial sac.l.2 Feigenbaum 3 reported two cases of electrical alternation in which echocardiography demonstrated significant anterior-posterior oscillations of the heart, tending to support this explanation. This report presents an additional case of pericardial effusion and total electrical alternation with marked movement of the heart documented by echocardiography. This patient also had pulsus alternans, which is rarely associated with electrical alternans,2.3 and was studied by phonocardiography and vectorcardiography as well as ultrasonic cardiography. CASE REpORT
The patient, an 18-year-old man, was stabbed in the abdomen on November 10, 1968. Exploratory laparotomy revealed a lacerated spleen and a 3 em rent in the posterior °From the Deparbnents of Medicine and Radiology, Albert Einstein College of Medicine, Lincoln Hospital, Bronx, New York.
,. /
}
/
FIGURE 2. Vectorcardiogram (Frank system with the point of the teardrop leading). Frontal and horizontal loops during electrical alternation. A and B represent the two extremes in position. C is an intermediate position occasionally noted. leaf of the left diaphragm. After splenectomy and repair of the diaphragm, tube drainage of the accompanying hemothorax was complicated by an empyema which responded to antibiotics. The patient was discharged following resolution of the empyema. At the time of discharge he had no cardiovascular symptoms, although radiographs of the chest showed thickened pleura on the left. The cardiac silhouette was not enlarged. The patient was re-admitted on January 16, 1969 with a three-day history of dyspnea on exertion and increased abdominal girth. Physical Examination Blood pressure was 120/80, falling to 100/60 with deep inspiration. Pulse rate was 120 and regular. When the patient held his breath, the pulse alternated in intensity. The neck
FIGURE 1. Initial electrocardiogram demonstrating total electrical alternation. The T wave alternation is best seen in lead VI. The QRS alternation is most pronounced in leads 1 and V4.
CHEST, VOL. 59, NO.3, MARCH 1971
GABOR, WINSBERG AND BLOOM
342
I
veins were distended. There was dullness to percussion, diminished breath sounds and increased fremitus over the lower third of the rij.(ht hemithorax. The first heart sound was of alternatinj.( intensity. The liver edge was palpable 12 cm helow the right costal marj.(in and shifting dullness was present. Dehydrocholic acid (Decholin) circulation time was 21 sec and the central venous pressure was 40 em of water. Chest x-ray film showed that the cardiac silhouette had enlarged markedly since the previous admission. There were hilateral pleural effusions, greater on the right.
'j
FIGURE 3. Simultaneous record of the phonocardiogram, electrocardiogram, and indirect carotid pulse taken with an Electronics for Medicine multi channel recorder using TS-I B pulse and sound microphones and a 50-500 cycle per second filter for the sound recordings. The time lines are 40 msec apart. There is alternation of the carotid pulse. Alternating intensity of the first heart sound and an early systolic murmur, present with every other beat, are shown on the phonocardiogram. Electrical alternation is shown on the electrocardiogram.
The electrocardiogram (Fig I) demonstrated total electrical alternation in all leads with a two beat cycle. ST segment elevations and T wave inversions were non-specific, but compatible with pericarditis.
Other Examinations The vectorcardiogram (Fig 2) in frontal and horizontal planes also demonstrated alternation. Sagittal plane vectorcardiogram was not performed. The QRS loop shifted from a
FIGURE 4A (left). Echocardiogram made with Hoffrel lOlA ultrasonoscope and 704 sweep attachinent. 2 mHz transducer. An echo-free space is demonstrated between the anterior heart wall and the anterior chest wall-pericardium and between the posterior heart wall and lung pericardium. The anterior and posterior heart walls are seen to move congmously. FIGURE 4B. The transducer is placed in the 5th interspace and aimed medially. The cross section of heart transversed by the ultrasonic beam varies so greatly with each QRS complex that it is reasonable to assume that one is seeing a near cardiac diameter with the normal QRS complex, whereas one is only striking the myocardium tangentially with the abnormal QRS complex.
CHEST, VOL. 59, NO.3, MARCH 1971
PERICARDIAL EFFUSION
343 Ventricular and atrial irritability were manifested by VPC's and runs of paroxysmal atrial tachycardia, but subsided shortly after the pericardial catheter was removed. Repeat ultrasonic studies (Fig 5) showed that there was fluid remaining in front of the right ventricle and behind the left ventricle, but the ventricular walls moved toward each other at the same frequency as the QRS complexes. Echocardiograms made before discharge showed complete clearing of fluid. DISCUSSION
posterior
FIGURE 5. Twenty-four hours after pericardial tap an echo-free zone is demonstrated behind the left ventricle. The pulsation of the left ventricle is now normal. Anterior excursion occurs after the QRS complex. marked posterior and inferior orientation to a left and more anterior position without change in conduction. There was a shift in the maximum QRS vector of 27° in the frontal plane and 80° in the horizontal plane. An intermediate position was occasionally noted. Indirect carotid pulye tracing confirmed the pulsus paradoxus and pulsus altemans noted on physical examination (Fig 3). Simultaneous phonocardiography demonstrated an early systolic murmur and increased intensity of the first heart sound on the beats corresponding to the weaker carotid pulsation. Echocardiogram (Fig 4A and B) showed an echo-free zone between the chest wall and the anterior heart wall and between the posterior heart wall and pericardium-lung posteriorly. Both the anterior and posterior heart walls showed a large anterior-posterior swing of about 4 cm average amplitude, the frequency of which was half that of the pulse. The two heart walls moved in the same direction rather than toward each other. The normal QRS complex apparently corresponded to the more posterior location of the heart, whereas the abnormal one occurred at its most anterior point of excursion. Pendulous excursions of the heart were large enough to obscure ventricular contractions. Course
Using a sub-xyphoid approach, a polyethylene catheter was inserted percutaneously into the pericardial sac. The pressure in the sac was 37 cm water. Over a period of 24 hours, 1800 ml of sero-sanguinous fluid was removed. Pulsus alternans and pulsus paradoxus disappeared. Repeat electrocardiograms no longer showed electrical alternation.
CHEST, VOL. 59, NO.3, MARCH 1971
This case of traumatic pericarditis provides additional evidence for the theoryl-r. that electrical alternation is the result of changes in cardiac position. The echocardiogram shows that the heart occupies an anterior position with one beat and a posterior position with the next. One of the echocardiographic tracings (Fig 4B) shows that the excursion of the heart is in the lateral direction, as well as in the antero-posterior direction. In this tracing there is a periodic alternation in the depth of the heart transversed by the ultrasonic beam. The disparity between maximal and minimal depths is much too great to be explained by any conceivable change in the cardiac volume. We believe that the ultrasonic beam is transversing a diameter or near diameter at one time and a secant or tangent at another, thus resulting in a sinusoid curve. The shift in anatomic position corresponds to shifts in electrical axis observed in the electrocardiogram and vectorcardiogram. The electrical shift in the horizontal plane supports motion about a superior-inferior axis. This rotational pendular movement has been attributed to the fixation of the heart by the great vessels and the rotational forces exerted by the bulbospiral muscles of the ventricle. l Additionally, frontal plane electrical alternation as shown by the electrocardiogram and vectorcardiogram, combined with the left-right and anterior-posterior oscillations demonstrated by echocardiograms indicate to and fro pendulous motion of the freely suspended apical portions of the ventricles. As in Feigenbaum's casesa of electrical alternans, the frequency of pendulous motion is one-half that of the heart rate. A heart rate between 108 and 125 seems to be critical for obtaining this ratio.~ The movement depends upon the mass of the suspended ventricles, the arm of the pendulum which they form, the vector sum of the forces applied, and the viscosity of the fluid. If the heart rate and pendulous motion were out of phase, the repetitive initiating and restoring forces might cancel each other. This case is also of interest since the patient had traumatic pericarditis. The previously reported cases of electrical alternans were in malignant, uremic or tuberculous pericardial effusions. As suspected by Littman and Spodick,~ the phenomenon of electrical alternation is related to the extent of effusion rather than its etiology. Fixation of the pericardium does not seem to be a necessary condition. Pulsus alternans is a very rare concomitant of electriElectrical alternacal alternans in pericardial effusion.~ tion can be adequately explained by the documented
SILVER ET AL
344 positional changes in the heart, and we are inclined to believe that the mechanical alternation was related to the same phenomena, since both disappeared after removal of the pericardiaI fluid. It is possible that at one of the extremes of position of the pendulous excursions of the heart, there is enough anatomic distortion to prevent effective contraction and ejection. Outflow or inflow obstruction might be produced by this distortion. The early systolic murmur which occurred with the weaker carotid pulses suggests some outflow obstruction of the left ventricle. REFERENCES
2 3 4 5
McGregor M, Baskind E: Electrical alternans in pericardial effusion. Circulation, 11 :837, 1955 Littman D, Spodick DH: Total electrical alternation in pericardial disease. Circulation, 13:912, 1953 Feigenbaum H, Zaky A, Grabhorn LL: Cardiac motion in patients with pericardial effusion. Circulation, 24:611, 1966 Price EC, Dennis EW: Electrical alternans, its mechanism demonstrated. Circulation, 40: Supplement III, 165, 1969 Adams DF: Authors comments on reviews. Investigative Radiol 4:288, 1969
Intracardiac Catheter as a Foreign Body of Six Years' Duration Resulting in Endocarditis* Walter Silver, M.D., Aurora DeGuzman, M.D., Howard A. loos, M.D., and Antonio A. Garzon, M.D.
This case report describes the presence of a catheter in the heart for six years resulting from a ventriculoatrial shunt for the alleviation of hydrocephalus, with the development of persistent bacteremia of 17 weeks' duration. Treatment with antibiotics was unsuccessful until the source of the infection was removed. The presence of the catheter in the right ventricle, main pulmonary artery and left pulmonary artery presented the interesting hemodynamic and clinical features of pulmonary insufficiency and tricuspid stenosis. Ventriculoatrial shunt for alleviation of hydrocephalus was introduced· by Pudenz in 1957,1 and complications from this procedure were reported as early as 1959. 2 In 1961, Emery and HiltonS described cardiopulmonary complications in postmortem studies in 14 of 15 patients who had had this shunting procedure. Catheter dislodgement and embolization have been described only five times,4.7 and surgical removal followed within two weeks after discovery of the embolization in all cases. In our case, the distal end of the catheter was discovered to be missing when the patient was ten months of age (eight months after insertion), °From the Departments of Pediatrics and Surgery, Maimonides Medical Center and State University of New York, Downstate Medical Center, Brooklyn.
FIGURE 1. Arrow points to catheter in the neck which is part of the presently functioning ventriculo-pleural shunt. but it was not removed for more than six years. We know of no previous case in which a catheter has remained free in the cardiopulmonary system for such an extended period. CASE REPORT
A seven-year-old Caucasian girl was admitted to Maimonides Medical Center on April 23, 1969 for fever of unknown origin of one month's duration. In December, 1962, when the patient was two months old, a ventriculoatrial shunt was performed for hydrocephalus. In September, 1963, she developed signs of increased intracranial pressure and it was suspected that the shunt was no longer functioning. Surgical exploration revealed that the distal portion of the catheter was missing, and a new one was inserted. In September, 1965, dysfunction of the ventriculoatrial shunt necessitated replacement with a ventriculopleural shunt, which is presently still functioning. She has had five other hospitalizations since 1964 for recurrent pyelonephritis and hydronephrosis. On the date of admission, she was a bright, intelligent seven-year-old girl in no acute distress. Her rectal temperature was 102.2° F, her heart rate was 120 beats per minute, respiratory rate 28 per minute, and blood pressure 90/60 mm Hg. The head was normal in size and shape; a valve was palpated above the right ear and the tubing was traced along the posterior neck. The neurologic examination was normal except for left esotropia. Other positive findings were limited to the auscultatory examination of the heart. The first heart sound was normal in intensity and was best heard at the apex. The second heart sound was best heard at the base, was normal in intensity and exhibited physiologic splitting. A i
i II I I'
,:!' I
111
I I !I
" '
FIGURE 2. Phonocardiogram recorded along the lower left sternal border showing a diamond-shaped systolic ejection murmur and diastolic murmur with presystolic accentuation.
CHEST, VOL. 59, NO.3, MARCH 1971
Electrical and Mechanical Alternation in Pericardial Effusion *
c:
H
George E. Gabor, M.D., Fred Winsberg, M.D., and Henry S. Bloom, M.D.
In a case of traumatic pericardial effusion with electrical and mechanical alternation, ultrasonic cardiography demonstrated excessive oscillatory motion of the heart. This motion occurred in both anteroposterior and left-to-right directions. The frequency of the motion was half the pulse rate and thus readily explains the electrical alternation. Pericardiocentesis abolished both of these phenomena.
r I
,I
E
lectrical alternation in patients with massive pericardia! effusion has been attributed to the fact that the heart changes in position with alternate beats when suspended in a large, fluid-filled pericardial sac.l.2 Feigenbaum 3 reported two cases of electrical alternation in which echocardiography demonstrated significant anterior-posterior oscillations of the heart, tending to support this explanation. This report presents an additional case of pericardial effusion and total electrical alternation with marked movement of the heart documented by echocardiography. This patient also had pulsus alternans, which is rarely associated with electrical alternans,2.3 and was studied by phonocardiography and vectorcardiography as well as ultrasonic cardiography. CASE REpORT
The patient, an 18-year-old man, was stabbed in the abdomen on November 10, 1968. Exploratory laparotomy revealed a lacerated spleen and a 3 em rent in the posterior °From the Deparbnents of Medicine and Radiology, Albert Einstein College of Medicine, Lincoln Hospital, Bronx, New York.
,. /
}
/
FIGURE 2. Vectorcardiogram (Frank system with the point of the teardrop leading). Frontal and horizontal loops during electrical alternation. A and B represent the two extremes in position. C is an intermediate position occasionally noted. leaf of the left diaphragm. After splenectomy and repair of the diaphragm, tube drainage of the accompanying hemothorax was complicated by an empyema which responded to antibiotics. The patient was discharged following resolution of the empyema. At the time of discharge he had no cardiovascular symptoms, although radiographs of the chest showed thickened pleura on the left. The cardiac silhouette was not enlarged. The patient was re-admitted on January 16, 1969 with a three-day history of dyspnea on exertion and increased abdominal girth. Physical Examination Blood pressure was 120/80, falling to 100/60 with deep inspiration. Pulse rate was 120 and regular. When the patient held his breath, the pulse alternated in intensity. The neck
FIGURE 1. Initial electrocardiogram demonstrating total electrical alternation. The T wave alternation is best seen in lead VI. The QRS alternation is most pronounced in leads 1 and V4.
CHEST, VOL. 59, NO.3, MARCH 1971
GABOR, WINSBERG AND BLOOM
342
I
veins were distended. There was dullness to percussion, diminished breath sounds and increased fremitus over the lower third of the rij.(ht hemithorax. The first heart sound was of alternatinj.( intensity. The liver edge was palpable 12 cm helow the right costal marj.(in and shifting dullness was present. Dehydrocholic acid (Decholin) circulation time was 21 sec and the central venous pressure was 40 em of water. Chest x-ray film showed that the cardiac silhouette had enlarged markedly since the previous admission. There were hilateral pleural effusions, greater on the right.
'j
FIGURE 3. Simultaneous record of the phonocardiogram, electrocardiogram, and indirect carotid pulse taken with an Electronics for Medicine multi channel recorder using TS-I B pulse and sound microphones and a 50-500 cycle per second filter for the sound recordings. The time lines are 40 msec apart. There is alternation of the carotid pulse. Alternating intensity of the first heart sound and an early systolic murmur, present with every other beat, are shown on the phonocardiogram. Electrical alternation is shown on the electrocardiogram.
The electrocardiogram (Fig I) demonstrated total electrical alternation in all leads with a two beat cycle. ST segment elevations and T wave inversions were non-specific, but compatible with pericarditis.
Other Examinations The vectorcardiogram (Fig 2) in frontal and horizontal planes also demonstrated alternation. Sagittal plane vectorcardiogram was not performed. The QRS loop shifted from a
FIGURE 4A (left). Echocardiogram made with Hoffrel lOlA ultrasonoscope and 704 sweep attachinent. 2 mHz transducer. An echo-free space is demonstrated between the anterior heart wall and the anterior chest wall-pericardium and between the posterior heart wall and lung pericardium. The anterior and posterior heart walls are seen to move congmously. FIGURE 4B. The transducer is placed in the 5th interspace and aimed medially. The cross section of heart transversed by the ultrasonic beam varies so greatly with each QRS complex that it is reasonable to assume that one is seeing a near cardiac diameter with the normal QRS complex, whereas one is only striking the myocardium tangentially with the abnormal QRS complex.
CHEST, VOL. 59, NO.3, MARCH 1971
PERICARDIAL EFFUSION
343 Ventricular and atrial irritability were manifested by VPC's and runs of paroxysmal atrial tachycardia, but subsided shortly after the pericardial catheter was removed. Repeat ultrasonic studies (Fig 5) showed that there was fluid remaining in front of the right ventricle and behind the left ventricle, but the ventricular walls moved toward each other at the same frequency as the QRS complexes. Echocardiograms made before discharge showed complete clearing of fluid. DISCUSSION
posterior
FIGURE 5. Twenty-four hours after pericardial tap an echo-free zone is demonstrated behind the left ventricle. The pulsation of the left ventricle is now normal. Anterior excursion occurs after the QRS complex. marked posterior and inferior orientation to a left and more anterior position without change in conduction. There was a shift in the maximum QRS vector of 27° in the frontal plane and 80° in the horizontal plane. An intermediate position was occasionally noted. Indirect carotid pulye tracing confirmed the pulsus paradoxus and pulsus altemans noted on physical examination (Fig 3). Simultaneous phonocardiography demonstrated an early systolic murmur and increased intensity of the first heart sound on the beats corresponding to the weaker carotid pulsation. Echocardiogram (Fig 4A and B) showed an echo-free zone between the chest wall and the anterior heart wall and between the posterior heart wall and pericardium-lung posteriorly. Both the anterior and posterior heart walls showed a large anterior-posterior swing of about 4 cm average amplitude, the frequency of which was half that of the pulse. The two heart walls moved in the same direction rather than toward each other. The normal QRS complex apparently corresponded to the more posterior location of the heart, whereas the abnormal one occurred at its most anterior point of excursion. Pendulous excursions of the heart were large enough to obscure ventricular contractions. Course
Using a sub-xyphoid approach, a polyethylene catheter was inserted percutaneously into the pericardial sac. The pressure in the sac was 37 cm water. Over a period of 24 hours, 1800 ml of sero-sanguinous fluid was removed. Pulsus alternans and pulsus paradoxus disappeared. Repeat electrocardiograms no longer showed electrical alternation.
CHEST, VOL. 59, NO.3, MARCH 1971
This case of traumatic pericarditis provides additional evidence for the theoryl-r. that electrical alternation is the result of changes in cardiac position. The echocardiogram shows that the heart occupies an anterior position with one beat and a posterior position with the next. One of the echocardiographic tracings (Fig 4B) shows that the excursion of the heart is in the lateral direction, as well as in the antero-posterior direction. In this tracing there is a periodic alternation in the depth of the heart transversed by the ultrasonic beam. The disparity between maximal and minimal depths is much too great to be explained by any conceivable change in the cardiac volume. We believe that the ultrasonic beam is transversing a diameter or near diameter at one time and a secant or tangent at another, thus resulting in a sinusoid curve. The shift in anatomic position corresponds to shifts in electrical axis observed in the electrocardiogram and vectorcardiogram. The electrical shift in the horizontal plane supports motion about a superior-inferior axis. This rotational pendular movement has been attributed to the fixation of the heart by the great vessels and the rotational forces exerted by the bulbospiral muscles of the ventricle. l Additionally, frontal plane electrical alternation as shown by the electrocardiogram and vectorcardiogram, combined with the left-right and anterior-posterior oscillations demonstrated by echocardiograms indicate to and fro pendulous motion of the freely suspended apical portions of the ventricles. As in Feigenbaum's casesa of electrical alternans, the frequency of pendulous motion is one-half that of the heart rate. A heart rate between 108 and 125 seems to be critical for obtaining this ratio.~ The movement depends upon the mass of the suspended ventricles, the arm of the pendulum which they form, the vector sum of the forces applied, and the viscosity of the fluid. If the heart rate and pendulous motion were out of phase, the repetitive initiating and restoring forces might cancel each other. This case is also of interest since the patient had traumatic pericarditis. The previously reported cases of electrical alternans were in malignant, uremic or tuberculous pericardial effusions. As suspected by Littman and Spodick,~ the phenomenon of electrical alternation is related to the extent of effusion rather than its etiology. Fixation of the pericardium does not seem to be a necessary condition. Pulsus alternans is a very rare concomitant of electriElectrical alternacal alternans in pericardial effusion.~ tion can be adequately explained by the documented
SILVER ET AL
344 positional changes in the heart, and we are inclined to believe that the mechanical alternation was related to the same phenomena, since both disappeared after removal of the pericardiaI fluid. It is possible that at one of the extremes of position of the pendulous excursions of the heart, there is enough anatomic distortion to prevent effective contraction and ejection. Outflow or inflow obstruction might be produced by this distortion. The early systolic murmur which occurred with the weaker carotid pulses suggests some outflow obstruction of the left ventricle. REFERENCES
2 3 4 5
McGregor M, Baskind E: Electrical alternans in pericardial effusion. Circulation, 11 :837, 1955 Littman D, Spodick DH: Total electrical alternation in pericardial disease. Circulation, 13:912, 1953 Feigenbaum H, Zaky A, Grabhorn LL: Cardiac motion in patients with pericardial effusion. Circulation, 24:611, 1966 Price EC, Dennis EW: Electrical alternans, its mechanism demonstrated. Circulation, 40: Supplement III, 165, 1969 Adams DF: Authors comments on reviews. Investigative Radiol 4:288, 1969
Intracardiac Catheter as a Foreign Body of Six Years' Duration Resulting in Endocarditis* Walter Silver, M.D., Aurora DeGuzman, M.D., Howard A. loos, M.D., and Antonio A. Garzon, M.D.
This case report describes the presence of a catheter in the heart for six years resulting from a ventriculoatrial shunt for the alleviation of hydrocephalus, with the development of persistent bacteremia of 17 weeks' duration. Treatment with antibiotics was unsuccessful until the source of the infection was removed. The presence of the catheter in the right ventricle, main pulmonary artery and left pulmonary artery presented the interesting hemodynamic and clinical features of pulmonary insufficiency and tricuspid stenosis. Ventriculoatrial shunt for alleviation of hydrocephalus was introduced· by Pudenz in 1957,1 and complications from this procedure were reported as early as 1959. 2 In 1961, Emery and HiltonS described cardiopulmonary complications in postmortem studies in 14 of 15 patients who had had this shunting procedure. Catheter dislodgement and embolization have been described only five times,4.7 and surgical removal followed within two weeks after discovery of the embolization in all cases. In our case, the distal end of the catheter was discovered to be missing when the patient was ten months of age (eight months after insertion), °From the Departments of Pediatrics and Surgery, Maimonides Medical Center and State University of New York, Downstate Medical Center, Brooklyn.
FIGURE 1. Arrow points to catheter in the neck which is part of the presently functioning ventriculo-pleural shunt. but it was not removed for more than six years. We know of no previous case in which a catheter has remained free in the cardiopulmonary system for such an extended period. CASE REPORT
A seven-year-old Caucasian girl was admitted to Maimonides Medical Center on April 23, 1969 for fever of unknown origin of one month's duration. In December, 1962, when the patient was two months old, a ventriculoatrial shunt was performed for hydrocephalus. In September, 1963, she developed signs of increased intracranial pressure and it was suspected that the shunt was no longer functioning. Surgical exploration revealed that the distal portion of the catheter was missing, and a new one was inserted. In September, 1965, dysfunction of the ventriculoatrial shunt necessitated replacement with a ventriculopleural shunt, which is presently still functioning. She has had five other hospitalizations since 1964 for recurrent pyelonephritis and hydronephrosis. On the date of admission, she was a bright, intelligent seven-year-old girl in no acute distress. Her rectal temperature was 102.2° F, her heart rate was 120 beats per minute, respiratory rate 28 per minute, and blood pressure 90/60 mm Hg. The head was normal in size and shape; a valve was palpated above the right ear and the tubing was traced along the posterior neck. The neurologic examination was normal except for left esotropia. Other positive findings were limited to the auscultatory examination of the heart. The first heart sound was normal in intensity and was best heard at the apex. The second heart sound was best heard at the base, was normal in intensity and exhibited physiologic splitting. A i
i II I I'
,:!' I
111
I I !I
" '
FIGURE 2. Phonocardiogram recorded along the lower left sternal border showing a diamond-shaped systolic ejection murmur and diastolic murmur with presystolic accentuation.
CHEST, VOL. 59, NO.3, MARCH 1971