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Floppy mitral whistle heard across the room
Letters to the Editor
deviation. We presented some data on this topic at the X I I t h International Symposium of Vectorcardiography.~ Although the selection criteria were slightly different, the results of both studies compare favorably in many respects. In our study 100 patients were selected out of a group of abou~ 2,000 providing one of the following criteria were positive: a frontal maximal vector oriented to 0 degrees or more superiorly and/or a QRS mean axis (A QRS) of - 3 0 degrees or more superiorly. There was a large range in the age of the patients with predominance for elderly patients: 57 were older than 50 years, 27 older than 70 years. Our clinical diagnosis showed even more coronary atherosclerosis (66 per cent) than in this paper, 55 patients presenting with electrical signs of infarction. In another 13 patients hypertension or cerebrovascular diseases were found. Our number of patients with chronic pulmonary disease was much smaller, but this might be due to a rather restricted number of such patients in our clinic; our subsequent experience certainly agrees more with the data of the abovementioned paper. Left axis deviation due to loss of inferior forces is an interesting entity that is sometimes confused with left anterior hemiblock and is seldom mentioned in textbooks; differential diagnosis with hemiblock could be made by clockwise rotation of the VCG loop in the frontal projection in all our cases; moreover, the loops of inferior infarction were located significantly lower than those of hemiblock and of hemiblock plus infarction (,~ QRS - 3 3 degrees versus - 5 5 degrees). The frequency of left ventricular hypertrophy and complete left bundle branch block in our study as well as the study by Drs. Grayzel and Neyshaboori was surprisingly low (3 patients of each). This illustrates that, in contrast to what is mentioned in the older literature , both these entities are not a frequent cause of left axis deviation.
Denis L. Clement, M.D. Academic Hospital Department of Cardiology De Pintelaan 135 D 9000 Gent, Belgium REFERENCES 1. Grayzel, J., and Neyshaboori, M.: Left-axis deviation: etiologic factors in one-hundred patients, AM. HEART J. 89:419, 1975. 2. Clement, D., Snoeck, J., and Pannier, R.: A clinical study of the superior oriented QRS s E loop in the frontal projection, Proc. XII Internat. Coll. Vectorcardiographicum, Presses Academiques Europeennes, Brussels, 1972, pp. 86-90.
girl, was at home just before Christmas when she and her mother, who was sitting across the room from her (estimate of 5 feet away), heard a peculiar squeaking rhythmic noise emanating from the girl's chest. The mother, trying to find the source of the squeak, asked the girl to stop breathing and hold still for a moment. To their surprise, the squeak was still there and was synchronous with the girl's pulse. The mother immediately rushed her to the local physician and his nurse, who confirmed the noise but could not make anything out of it Other than a Grade VI/VI systolic murmur. Since the child was healthy, the physician reassured the family and arranged for the child to be seen in our Pediatric Cardiac Clinic. Our physical examination revealed a slender but healthylooking girl with no features to suggest Marfan's syndrome. Our initial examination of the chest was completely normal except for a soft midsystolic click. No murmur was heard with or without the stethoscope. Upon questioning the child and the mother further, they told us that the squeak is not always heard; it sometimes disappears for two to five days, and when it is heard, it usually lasts for only a few minutes. They also stated that when the child runs home from school or when she is emotionally excited the whistle often recurs and the heart rate is usually around 120 per minute when the whistle is heard. After asking the child to perform 10 sit-ups, to our surprise, a Grade III/VI high-pitched mid-systolic squeak was heard at the apex. Cardiac catheterization with cineangiography was performed and the only abnormality found was a prolapse of the posterior leaflet of the mitral valve. No mitral insufficiency was seen, and the murmur and mid-systolic click disappeared during the two days of hospitalization. Our speculation about the origin of the sound is that the loose floppy mitral leaflets may enter a certain position at a certain body posture or activity, resulting in a mild mitral insufficiency with fluttering of the loose mitral leaflets in the course of the jet stream of blood, thus creating the whistling sound. In 1880, William Osler reported an unusual heart murmur that could be heard at a distance of 3 feet and 2 inches from the chest wall of a 12-year-old well-nourished girl. That murmur also disappeared suddenly and could not be detected on most careful examination. To our knowledge this represents the third reported case of a floppy mitral whistle that can be heard across the room. It is interesting that all these cases were females and that the whistle was heard for the first time at the ages seven to twelve years.
Zuhdi Lababidi, M.D. Director of Cardiology Department of Child Health University of Missouri School of Medicine University of Missouri Medical Center Columbia, Mo. 65201
Floppy mitral w h i s t l e h e a r d across t h e room To the Editor: The article by Dr. Segall (Am. Heart J. 91:269-272, 1976) was of great interest to us at the University of Missouri Medical Center because we had a similar experience a week before the article was published. Dr. Segall reported a 23-year-old young woman who heard a peculiar noise emanating from inside her chest at the age of twelve years, which soon disappeared but recurred occasionally during the next ten years. Echocardiography showed the classic midsystolic buckling of the mitral valve. Our patient A.H. (UMMC No. 11-32-78-4), a seven-year-old
A m e r i c a n Hea r t J o u r n a l
REFERENCES 1. Osler, W.: On a remarkable heart murmur, heard at a distance from the chest wall, Med. Times and Gaz. Lond,, ii, 432-433, 1880. Patient presented, Medico Chirurgical Society of Montreal April 30, 1880. Reported in Can. Med. Surg. J. VII1:518-519, 1879-1880. 2. Segall, H. N.: Autoauscultation in a patient with floppy mitral valve syndrome, AM. HEART J. 91:269-272, 1976.
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deviation. We presented some data on this topic at the X I I t h International Symposium of Vectorcardiography.~ Although the selection criteria were slightly different, the results of both studies compare favorably in many respects. In our study 100 patients were selected out of a group of abou~ 2,000 providing one of the following criteria were positive: a frontal maximal vector oriented to 0 degrees or more superiorly and/or a QRS mean axis (A QRS) of - 3 0 degrees or more superiorly. There was a large range in the age of the patients with predominance for elderly patients: 57 were older than 50 years, 27 older than 70 years. Our clinical diagnosis showed even more coronary atherosclerosis (66 per cent) than in this paper, 55 patients presenting with electrical signs of infarction. In another 13 patients hypertension or cerebrovascular diseases were found. Our number of patients with chronic pulmonary disease was much smaller, but this might be due to a rather restricted number of such patients in our clinic; our subsequent experience certainly agrees more with the data of the abovementioned paper. Left axis deviation due to loss of inferior forces is an interesting entity that is sometimes confused with left anterior hemiblock and is seldom mentioned in textbooks; differential diagnosis with hemiblock could be made by clockwise rotation of the VCG loop in the frontal projection in all our cases; moreover, the loops of inferior infarction were located significantly lower than those of hemiblock and of hemiblock plus infarction (,~ QRS - 3 3 degrees versus - 5 5 degrees). The frequency of left ventricular hypertrophy and complete left bundle branch block in our study as well as the study by Drs. Grayzel and Neyshaboori was surprisingly low (3 patients of each). This illustrates that, in contrast to what is mentioned in the older literature , both these entities are not a frequent cause of left axis deviation.
Denis L. Clement, M.D. Academic Hospital Department of Cardiology De Pintelaan 135 D 9000 Gent, Belgium REFERENCES 1. Grayzel, J., and Neyshaboori, M.: Left-axis deviation: etiologic factors in one-hundred patients, AM. HEART J. 89:419, 1975. 2. Clement, D., Snoeck, J., and Pannier, R.: A clinical study of the superior oriented QRS s E loop in the frontal projection, Proc. XII Internat. Coll. Vectorcardiographicum, Presses Academiques Europeennes, Brussels, 1972, pp. 86-90.
girl, was at home just before Christmas when she and her mother, who was sitting across the room from her (estimate of 5 feet away), heard a peculiar squeaking rhythmic noise emanating from the girl's chest. The mother, trying to find the source of the squeak, asked the girl to stop breathing and hold still for a moment. To their surprise, the squeak was still there and was synchronous with the girl's pulse. The mother immediately rushed her to the local physician and his nurse, who confirmed the noise but could not make anything out of it Other than a Grade VI/VI systolic murmur. Since the child was healthy, the physician reassured the family and arranged for the child to be seen in our Pediatric Cardiac Clinic. Our physical examination revealed a slender but healthylooking girl with no features to suggest Marfan's syndrome. Our initial examination of the chest was completely normal except for a soft midsystolic click. No murmur was heard with or without the stethoscope. Upon questioning the child and the mother further, they told us that the squeak is not always heard; it sometimes disappears for two to five days, and when it is heard, it usually lasts for only a few minutes. They also stated that when the child runs home from school or when she is emotionally excited the whistle often recurs and the heart rate is usually around 120 per minute when the whistle is heard. After asking the child to perform 10 sit-ups, to our surprise, a Grade III/VI high-pitched mid-systolic squeak was heard at the apex. Cardiac catheterization with cineangiography was performed and the only abnormality found was a prolapse of the posterior leaflet of the mitral valve. No mitral insufficiency was seen, and the murmur and mid-systolic click disappeared during the two days of hospitalization. Our speculation about the origin of the sound is that the loose floppy mitral leaflets may enter a certain position at a certain body posture or activity, resulting in a mild mitral insufficiency with fluttering of the loose mitral leaflets in the course of the jet stream of blood, thus creating the whistling sound. In 1880, William Osler reported an unusual heart murmur that could be heard at a distance of 3 feet and 2 inches from the chest wall of a 12-year-old well-nourished girl. That murmur also disappeared suddenly and could not be detected on most careful examination. To our knowledge this represents the third reported case of a floppy mitral whistle that can be heard across the room. It is interesting that all these cases were females and that the whistle was heard for the first time at the ages seven to twelve years.
Zuhdi Lababidi, M.D. Director of Cardiology Department of Child Health University of Missouri School of Medicine University of Missouri Medical Center Columbia, Mo. 65201
Floppy mitral w h i s t l e h e a r d across t h e room To the Editor: The article by Dr. Segall (Am. Heart J. 91:269-272, 1976) was of great interest to us at the University of Missouri Medical Center because we had a similar experience a week before the article was published. Dr. Segall reported a 23-year-old young woman who heard a peculiar noise emanating from inside her chest at the age of twelve years, which soon disappeared but recurred occasionally during the next ten years. Echocardiography showed the classic midsystolic buckling of the mitral valve. Our patient A.H. (UMMC No. 11-32-78-4), a seven-year-old
A m e r i c a n Hea r t J o u r n a l
REFERENCES 1. Osler, W.: On a remarkable heart murmur, heard at a distance from the chest wall, Med. Times and Gaz. Lond,, ii, 432-433, 1880. Patient presented, Medico Chirurgical Society of Montreal April 30, 1880. Reported in Can. Med. Surg. J. VII1:518-519, 1879-1880. 2. Segall, H. N.: Autoauscultation in a patient with floppy mitral valve syndrome, AM. HEART J. 91:269-272, 1976.
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