- Email: [email protected]
Murmurs of aortic stenosis and mitral insufficiency masquerading as one another
American
Heart Journal October, 1963, Volume 66, Number 4
Editorial
Murmurs of aortic stenosis
and
masquerading
as one
mitral
insufficiency
another
George E. Burch, M.D.* John H. Phillips, M.D. New Orleans, La.
T
he importance of an accurate diagnosis in clinical medicine is obvious. This is certainly true in cardiology. Contrary to recent trends toward complex instrumentation and methods in study, auscultation by experienced and capable clinicians and cardiologists is accurate, simple, innocuous, and applicable even in the patient’s home. Important considerations here lie in the interpretation and differential diagnosis of cardiac auscultatory phenomena. Even though the subject is a broad one, many practical advances in the understanding and application of auscultatory phenomena have been made.’ One special problem which deserves emphasis at the present time concerns the systolic murmurs of aortic stenosis and mitral insufficiency. It is well known, but not widely appreciated, that the murmur of aortic stenosis may masquerade as that of mitral insufficiency, and, conversely, that the murmur of mitral insufliciency may masquerade as that of aortic stenosis. In this respect, the fallacy of diagnosing the valvular origin From
of murmurs according to the precordial area of greatest intensity of the murmur is brought into its clearest perspective. One finds that in the diagnosis of murmurs the precordial location is the one most frequently used, and likewise misused, feature. Location and transmission of murmurs are of obvious importance, but pitfalls must be realized. As a point of orientation, the now popular classification of systolic murmurs into the ejection type or the regurgitant type2J merits brief review. Exceptions and suggested additions to this classification have been pointed out.4 Briefly, ejection murmurs are associated with an altered flow of blood across the semilunar valves. Aortic ejection murmurs begin shortly after the first heart sound and end shortly before the aortic second sound. These murmurs are limited to the period of ventricular systolic ejection and have a crescendodecrescendo or “diamond-shaped” configuration, being more intense near midsystole. Regurgitant valvular murmurs are not limited to the period of systolic ejec-
the Departments of Medicine, Tulane University School of Medicine. the Veterans Administration Hospital, New Orleans, La. This work supported by grants from the United States Public Health Service. Received for publication April 22, 1963. *Address: 1430 Tulane Ave., New Orleans, La. 70112
439
the Charity
Hospital
of Louisiana,
and
440
Burch and Phillips
tion, but are present throughout mechanical systole of the ventricle (holosystolic or pansystolic). The most common cause of this type of murmur in man is mitral regurgitation. It begins with and often obscures the first sound and ends at or slightly later than the aortic second sound. It tends to lack the crescendo-decrescendo quality, having a rather flat or “plateau” configuration or frequently a gradual late systolic accentuation. These differences in timing of the aortic “ejection” murmur and the mitral regurgitant murmur cannot be overemphasized. Furthermore, the hemodynamic reasons for these differences are obvious. A!though the murmur of aortic stenosis is usually maximal at the second right intercostal space near the sternum, at times it is also clearly audible at the apex, and occasionally it is maximal or even confined to the apex.*Js5 This obviously causes confusion with mitral insufficiency. Fortunately for the clinician, in such situations of atypical transmission the murmur usually retains its “ejection” characteristics with a crescendo-decrescendo configuration with peaking in mid-systole and ending shortly before the aortic second sound.6-8 Thus, not only the precise timing of the murmur but the configuration of intensity also aid in its correct diagnosis and differentiation from mitral insufficiency. Another helpful point is that, even though the aortic valvular systolic murmur may be soft to absent at the aortic area, it may be readill detected over the carotid artery in the neck, especially on the right side. It is interesting that at times the murmur of aortic stenosis, as it is transmitted to the apical region of the heart, may have a distinct musical quality and may or may not be associated with a harsh systolic murmur at the aortic area (Gallavardin phenomenon).g It is important to remember this dissociation in frequency components of murmurs which emanate from the same basic anatomic lesion. Thus, when aortic stenosis is suspected, one is less likely to erroneously attribute a musical murmur at the apex to mitral insufficiency. Awareness of this phenomenon and careful attention to other details pointed out herein will help avoid this error. That the murmur of mitral insufficiency
may mimic the murmur of aortic stenosis on auscultation is less well known. Classically, the murmur of mitral insufficient) is considered to be loudest at the apex, with radiation to the left axilla and left scapula, Several recent reports, however, have emphasized the fact that, occasionally, radiation may be toward the base, including the second right intercostal space, and even the neck, thus simulating the murmur of aortic stenosis.10-12 It has been suggested that in such instances of atypical radiation to the aortic area, mitral incompetence of primarily the posterior mitral leaflet exists. This tends to direct the regurgitant stream of blood forward and medially against the atria1 septum at the base of the aorta, with production of a murrnur.“~‘3 Thus, vibrations set up in the base of the aorta by the jet of blood account for transmission of the murmur to the base of the heart and even into the neck. Evidence for this mechanism is afforded by the detection of jet lesions of the endocnrdium in this area of the atrium in autopsied patients. Of interest is the increasing number of recent reports of ruptured chordae tendineae in which this mechanism has been advanced to explain the cause of the resulting mitral insufficiency which tends to produce a murmur that simulates the murmur of aortic stenosis.13-16 In one patient, not onl~v was the murmur loud at the aortic area, but it also had a distinct diamond-shaped configuration.*5 Recently reported 011 were two patients with mitral insufficiency, probably due to rheumatic fever, in whom the auscultatory findings simulated aortic stenosis.” ti\lthough there was no autopsy confirmation, the authors tended to believe that a similar jet mechanism was the cause. They remarked that, although murmurs over the precordium and to the right of the sternum are common in extreme mitral insufficiency with a giant left atrium,g such was not the case in their patients.l’ It would appear that, in the evaluation of a patient with possible mitral insufficiency masquerading as aortic stenosis, careful attention to auscultatory details can be very helpful. One mav find that the murmur at the aortic area-is truly holosystolic, i.e., it begins with the first sound and continues to and, particularly, through
Murmurs
the aortic second sound.17 This is of considerable value in realizing that the murmur is due to mitral insufficiency. Furthermore, mitral origin is favored when there is no tendency for the murmur to be diamond shaped (mid-systolic accentuation), and when the configuration is plateau, especially with a tendency to late.systolic accentuation. This latter feature is particularly distinctive of mitral insufficiency.18 Careful attention to the quality of the murmur is of further help in differential diagnosis, but differences of this nature are more difficult to detect with systolic than with diastolic murmurs.’ Typically, the murmur of mitral insufficiency is high pitched and blowing in quality, whereas that of aortic stenosis is lower pitched and harsh or rasping. There are frequent exceptions, however. A murmur of mitral insufficiency which occasionally causes confusion is that recently described which results from mechanical dysfunction (without rupture) of the left ventricular papillary muscles.lgJO This murmur is frequently diamond shaped in configuration, and, although loudest at the apex, it may occasionally radiate well to the aortic area, possibly simulating aortic stenosis.“” The distinguishing and important diagnostic auscultatory feature, however, is the fact that this is a circumscribed murmur of delayed or late onset, beginning after the first heart sound. It is not holosystolic. Furthermore, the electrocardiogram may be of distinct help in diagnosing it. Infarction or fibrosis of a papillary muscle is the primary cause of papillary muscle dysfunction of this type, and the lesions may be suspected electrocardiographically. 20~21In this respect, in the proper clinical setting, true rupture of either the anterolateral or posteromedial papillary muscle may be suspected clinically by electrocardiographic changes and the presence of a mitral insufficiency murn1ur.zo The murmur of a ruptured papillary muscle (or its attached chordae tendineae) differs from that of simple papillary muscle dysfunction, however, in that, although the murmur of a ruptured papillary muscle or chordae tendineae may have crescendodecrescendo characteristics, it is holosystolic in timing, beginning with the first heart sound, without delay.1ga20
of aortic stenosis and mitral
insu.ciency
441
Again, considering auscultatory differentiation of the murmurs of mitral insufficiency and aortic stenosis with atypical location, other observations can help. It has been pointed out in patients with aortic stenosis and atria1 fibrillation that the intensity of the murmur varies directly with the preceding cycle length, i.e., it is more intense after long pauses and less intense after shorter pauses.’ In mitral insufficiency this was found not to be the case, since the intensity of the murmur here tends to be less related to the preceding cycle length. It has been suggested that the same reasoning may be applied equally well to other irregular rhythms, including premature contractions.7~8~12 In spite of the published .reports, in the presence of premature contractions we have noted occasional exceptions to this rule, as have others.17 Other auscultatory findings may be helpful in diagnosis. In mitral insufficiency, wide splitting of the second heart sound may occur because of the early closure of the aortic valve associated with a decreased duration of left ventricular systole.*~22 In the absence of right ventricular decompensation this splitting varies normally (widens) with inspiration.12 However, in aortic stenosis, because of a delay in closure of the aortic valve, the second sound may be only narrowly split and, indeed, show a reversed split (closure of the pulmonary valve precedes closure of the aortic valve). In the latter situation, paradoxical splitting would occur on respiration, i.e., a widening of the split on expiration and a narrowing on inspiration.’ Observations concerning the intensity of the mitral first heart sound and the aortic second sound may also be helpful. In pure mitral insufficiency (without mitral stenosis) with incompetence of both leaflets, the first sound would tend to be soft and tnerged with the loud systolic murmur,8,g,12 whereas in aortic stenosis this would not be expected. In an evaluation of the intensity of the first heart sound the effect of atrioventricular conduction time (P-R interval) must be considered.’ With respect to the aortic second sound, classicallv, the intensity should be reduced in nor& stenosis, whereas in mitral insufficiency it should be relatively normal. Exceptions to these generalizations are well known.
442
Although infrequently required, one procedure which is practical for bedside auscultation, and which can be useful in differential diagnosis, is the amyl-nitrite test.Z3 Briefly, careful auscultation is done during a11 d immediately after the patient inhales the amyl nitrite. The murmur of mitral insufficiency becomes softer and shorter during and for approximately 20 seconds after inhalation. Conversely, the murmur of aortic stenosis becomes louder after inhalation and reaches a peak intensity at approximately 30 to 4.5 secondsZ3 Pharmacologic manipulation of murmurs has also been done by the use of vasopresser agents. 24 In general, these agents cause changes which are the opposite of those produced by amyl nitrite. Lastly, in the clinical analysis of the problem of atypically localized murmurs of aortic stenosis and mitral insufficiency, one should take into consideration the many clues gained through a complete clinical evaluation. It is difficult to define the degree to which these should influence the diagnosis, but their significance in the purest sense is well known. These observations include arterial blood pressure, pulse pressure, type of pulse, roentgenographic localization of valve calcification, of specific chamber enlargement or of vascular change, electrocardiographic changes, the presence of detectable associated lesions, and many others. All of the clinical data should be considered, among which auscultation is an integral part. In summary, if one relies solely on the characteristic of location for the determination of the specific valvular origin of murmurs, gross errors will occasionally be made. Careful and thoughtful attention to detail must be exercised in order to avoid these pitfalls. REFERENCES 1.
2.
3. 4. 5.
Am. Heart J. October, 1963
Burch and Phillips
Phillips, J. H., and Burch, G. E.: Selected clues in cardiac auscultation, AM. HEART J. 63:1, 1962. Leatham, A.: Short communications. A classification of systolic murmurs. Proc. British Cardiac Society, Brit. Heart J. 17:.574, 1955. Leatham, A.: Systolic murmurs, Circulation 17:601, 1958. Shabetai, R., and Marshall, W. J.: Systolic murmurs, AM. HEART J. 65:412, 1963. Bergeron, J., Abelman, W. H., Vazquez-Milan, H., and Ellis, L. B.: Aortic stenosis. Clinical
6. 7.
8.
9.
10.
11.
12.
13.
14.
1.5.
16. 17.
18.
19.
20.
21.
22.
23.
24.
manifestations and course of the disease. Review of 100 proved cases, A.M.A. Arch. Int. Med. 94:911, 1954. Leatham, A.: The phonocardiogram of aortic stenosis, Brit. Heart J. 13:153, 1951. Henke, R. P., March, H. W., and Hultgren, H. N.: An aid to identification of the murmur of aortic stenosis with atypical location, XIII. HEART J. 60:354, 1960. Humphries, J., and McKusick, V.: The differentiation of organic and “innocent” systolic murmurs, Prog. Cardiovas. Dis. 5:152, 1962. Cardiovascular sound in McKusick, V. 4.: health and disease, Baltimore, 1958, Williams & Wilkins Company. Movitt, E., and Gerstl, B.: Pure mitral insufliciency of rheumatic origin in adults, Ann. Int. Med. 38:981, 1953. Edwards, J. E., and Burchell, H. B.: Endocardial and intimal lesions (jet impact) as possible sites of origin of murmurs, Circulation 18:946, 1958. Perloff, J. K., and Harvey, W. I’.: Auscultatory and phonocardiographic manifestations of pure mitral regurgitation, Prog. Cardiovas. Dis. 5:172, 1962. Osmundson, P. J., Callahan, J. A., and Edwards, J. E.: Mitral insuffi&ency from ruptured chordae tendineae simulating aortic stenosis, hoc. Staff. Meet. Mayo Clin. 33:235, 1958. R. J.: Mitral insufMiller, R., and Rearson, ficiency simulating aortic stenosis, New England I. Med. 260:1210. 1959. Shapiro, H. A., and Weiss, D. R.: Mitral insufficiency due to ruptured chordae tendineae simulating aortic stenosis, New England J. Med. 261:272, 1959. Case Records of the Massachusetts General Hospital, New England J. Med. 267:1033, 1962. Sleeper, J. C., Oigain, E. S., and McIntosh, H. D.: Mitral insufficiencv simulating aortic stenosis, Circulation 26:428: 1962. Leatham, A.: The place of phonocardiography in clinical cardiology, Prog. Cardiovas. Dis. 2:76, 1959. Burch, G. E., De Pasquale, N. P., and Phillips, J. H.: Clinical manifestations of papillary muscle dysfunction, A.M.A. Arch. Int. Med. 112:112, 1963. Phillips, J. I-I., Burch, G. E., and De Pasquale, N. I’.: The syndrome of papillary muscle dysfunction; its clinical recognition, Ann. Int. Med. (Submitted for publication.) Phillips, J. H., De Pasquale, N. P., and Burch, G. E.: The electrocardiogram in infarction of the anterolateral papillary muscle, AM. HEART J. 66:338, 1963. Perloff, J. Ii., and Harvey, W. P.: Mechanisms of fixed splitting of the second heart sound, Circulation 18:998, 19.58. Vogelpoel. L.. and Srhire, V.: The use of amyl nitrite in the diagnosis of systolic murmurs, Lancet 2:810, 1959. Endrys, J., and Bartova, A.: Pharmacologic methods in the phonocardiographic diagnosis of regurgitant murmurs, Brit. Heart J. 24:207, 1962.
Heart Journal October, 1963, Volume 66, Number 4
Editorial
Murmurs of aortic stenosis
and
masquerading
as one
mitral
insufficiency
another
George E. Burch, M.D.* John H. Phillips, M.D. New Orleans, La.
T
he importance of an accurate diagnosis in clinical medicine is obvious. This is certainly true in cardiology. Contrary to recent trends toward complex instrumentation and methods in study, auscultation by experienced and capable clinicians and cardiologists is accurate, simple, innocuous, and applicable even in the patient’s home. Important considerations here lie in the interpretation and differential diagnosis of cardiac auscultatory phenomena. Even though the subject is a broad one, many practical advances in the understanding and application of auscultatory phenomena have been made.’ One special problem which deserves emphasis at the present time concerns the systolic murmurs of aortic stenosis and mitral insufficiency. It is well known, but not widely appreciated, that the murmur of aortic stenosis may masquerade as that of mitral insufficiency, and, conversely, that the murmur of mitral insufliciency may masquerade as that of aortic stenosis. In this respect, the fallacy of diagnosing the valvular origin From
of murmurs according to the precordial area of greatest intensity of the murmur is brought into its clearest perspective. One finds that in the diagnosis of murmurs the precordial location is the one most frequently used, and likewise misused, feature. Location and transmission of murmurs are of obvious importance, but pitfalls must be realized. As a point of orientation, the now popular classification of systolic murmurs into the ejection type or the regurgitant type2J merits brief review. Exceptions and suggested additions to this classification have been pointed out.4 Briefly, ejection murmurs are associated with an altered flow of blood across the semilunar valves. Aortic ejection murmurs begin shortly after the first heart sound and end shortly before the aortic second sound. These murmurs are limited to the period of ventricular systolic ejection and have a crescendodecrescendo or “diamond-shaped” configuration, being more intense near midsystole. Regurgitant valvular murmurs are not limited to the period of systolic ejec-
the Departments of Medicine, Tulane University School of Medicine. the Veterans Administration Hospital, New Orleans, La. This work supported by grants from the United States Public Health Service. Received for publication April 22, 1963. *Address: 1430 Tulane Ave., New Orleans, La. 70112
439
the Charity
Hospital
of Louisiana,
and
440
Burch and Phillips
tion, but are present throughout mechanical systole of the ventricle (holosystolic or pansystolic). The most common cause of this type of murmur in man is mitral regurgitation. It begins with and often obscures the first sound and ends at or slightly later than the aortic second sound. It tends to lack the crescendo-decrescendo quality, having a rather flat or “plateau” configuration or frequently a gradual late systolic accentuation. These differences in timing of the aortic “ejection” murmur and the mitral regurgitant murmur cannot be overemphasized. Furthermore, the hemodynamic reasons for these differences are obvious. A!though the murmur of aortic stenosis is usually maximal at the second right intercostal space near the sternum, at times it is also clearly audible at the apex, and occasionally it is maximal or even confined to the apex.*Js5 This obviously causes confusion with mitral insufficiency. Fortunately for the clinician, in such situations of atypical transmission the murmur usually retains its “ejection” characteristics with a crescendo-decrescendo configuration with peaking in mid-systole and ending shortly before the aortic second sound.6-8 Thus, not only the precise timing of the murmur but the configuration of intensity also aid in its correct diagnosis and differentiation from mitral insufficiency. Another helpful point is that, even though the aortic valvular systolic murmur may be soft to absent at the aortic area, it may be readill detected over the carotid artery in the neck, especially on the right side. It is interesting that at times the murmur of aortic stenosis, as it is transmitted to the apical region of the heart, may have a distinct musical quality and may or may not be associated with a harsh systolic murmur at the aortic area (Gallavardin phenomenon).g It is important to remember this dissociation in frequency components of murmurs which emanate from the same basic anatomic lesion. Thus, when aortic stenosis is suspected, one is less likely to erroneously attribute a musical murmur at the apex to mitral insufficiency. Awareness of this phenomenon and careful attention to other details pointed out herein will help avoid this error. That the murmur of mitral insufficiency
may mimic the murmur of aortic stenosis on auscultation is less well known. Classically, the murmur of mitral insufficient) is considered to be loudest at the apex, with radiation to the left axilla and left scapula, Several recent reports, however, have emphasized the fact that, occasionally, radiation may be toward the base, including the second right intercostal space, and even the neck, thus simulating the murmur of aortic stenosis.10-12 It has been suggested that in such instances of atypical radiation to the aortic area, mitral incompetence of primarily the posterior mitral leaflet exists. This tends to direct the regurgitant stream of blood forward and medially against the atria1 septum at the base of the aorta, with production of a murrnur.“~‘3 Thus, vibrations set up in the base of the aorta by the jet of blood account for transmission of the murmur to the base of the heart and even into the neck. Evidence for this mechanism is afforded by the detection of jet lesions of the endocnrdium in this area of the atrium in autopsied patients. Of interest is the increasing number of recent reports of ruptured chordae tendineae in which this mechanism has been advanced to explain the cause of the resulting mitral insufficiency which tends to produce a murmur that simulates the murmur of aortic stenosis.13-16 In one patient, not onl~v was the murmur loud at the aortic area, but it also had a distinct diamond-shaped configuration.*5 Recently reported 011 were two patients with mitral insufficiency, probably due to rheumatic fever, in whom the auscultatory findings simulated aortic stenosis.” ti\lthough there was no autopsy confirmation, the authors tended to believe that a similar jet mechanism was the cause. They remarked that, although murmurs over the precordium and to the right of the sternum are common in extreme mitral insufficiency with a giant left atrium,g such was not the case in their patients.l’ It would appear that, in the evaluation of a patient with possible mitral insufficiency masquerading as aortic stenosis, careful attention to auscultatory details can be very helpful. One mav find that the murmur at the aortic area-is truly holosystolic, i.e., it begins with the first sound and continues to and, particularly, through
Murmurs
the aortic second sound.17 This is of considerable value in realizing that the murmur is due to mitral insufficiency. Furthermore, mitral origin is favored when there is no tendency for the murmur to be diamond shaped (mid-systolic accentuation), and when the configuration is plateau, especially with a tendency to late.systolic accentuation. This latter feature is particularly distinctive of mitral insufficiency.18 Careful attention to the quality of the murmur is of further help in differential diagnosis, but differences of this nature are more difficult to detect with systolic than with diastolic murmurs.’ Typically, the murmur of mitral insufficiency is high pitched and blowing in quality, whereas that of aortic stenosis is lower pitched and harsh or rasping. There are frequent exceptions, however. A murmur of mitral insufficiency which occasionally causes confusion is that recently described which results from mechanical dysfunction (without rupture) of the left ventricular papillary muscles.lgJO This murmur is frequently diamond shaped in configuration, and, although loudest at the apex, it may occasionally radiate well to the aortic area, possibly simulating aortic stenosis.“” The distinguishing and important diagnostic auscultatory feature, however, is the fact that this is a circumscribed murmur of delayed or late onset, beginning after the first heart sound. It is not holosystolic. Furthermore, the electrocardiogram may be of distinct help in diagnosing it. Infarction or fibrosis of a papillary muscle is the primary cause of papillary muscle dysfunction of this type, and the lesions may be suspected electrocardiographically. 20~21In this respect, in the proper clinical setting, true rupture of either the anterolateral or posteromedial papillary muscle may be suspected clinically by electrocardiographic changes and the presence of a mitral insufficiency murn1ur.zo The murmur of a ruptured papillary muscle (or its attached chordae tendineae) differs from that of simple papillary muscle dysfunction, however, in that, although the murmur of a ruptured papillary muscle or chordae tendineae may have crescendodecrescendo characteristics, it is holosystolic in timing, beginning with the first heart sound, without delay.1ga20
of aortic stenosis and mitral
insu.ciency
441
Again, considering auscultatory differentiation of the murmurs of mitral insufficiency and aortic stenosis with atypical location, other observations can help. It has been pointed out in patients with aortic stenosis and atria1 fibrillation that the intensity of the murmur varies directly with the preceding cycle length, i.e., it is more intense after long pauses and less intense after shorter pauses.’ In mitral insufficiency this was found not to be the case, since the intensity of the murmur here tends to be less related to the preceding cycle length. It has been suggested that the same reasoning may be applied equally well to other irregular rhythms, including premature contractions.7~8~12 In spite of the published .reports, in the presence of premature contractions we have noted occasional exceptions to this rule, as have others.17 Other auscultatory findings may be helpful in diagnosis. In mitral insufficiency, wide splitting of the second heart sound may occur because of the early closure of the aortic valve associated with a decreased duration of left ventricular systole.*~22 In the absence of right ventricular decompensation this splitting varies normally (widens) with inspiration.12 However, in aortic stenosis, because of a delay in closure of the aortic valve, the second sound may be only narrowly split and, indeed, show a reversed split (closure of the pulmonary valve precedes closure of the aortic valve). In the latter situation, paradoxical splitting would occur on respiration, i.e., a widening of the split on expiration and a narrowing on inspiration.’ Observations concerning the intensity of the mitral first heart sound and the aortic second sound may also be helpful. In pure mitral insufficiency (without mitral stenosis) with incompetence of both leaflets, the first sound would tend to be soft and tnerged with the loud systolic murmur,8,g,12 whereas in aortic stenosis this would not be expected. In an evaluation of the intensity of the first heart sound the effect of atrioventricular conduction time (P-R interval) must be considered.’ With respect to the aortic second sound, classicallv, the intensity should be reduced in nor& stenosis, whereas in mitral insufficiency it should be relatively normal. Exceptions to these generalizations are well known.
442
Although infrequently required, one procedure which is practical for bedside auscultation, and which can be useful in differential diagnosis, is the amyl-nitrite test.Z3 Briefly, careful auscultation is done during a11 d immediately after the patient inhales the amyl nitrite. The murmur of mitral insufficiency becomes softer and shorter during and for approximately 20 seconds after inhalation. Conversely, the murmur of aortic stenosis becomes louder after inhalation and reaches a peak intensity at approximately 30 to 4.5 secondsZ3 Pharmacologic manipulation of murmurs has also been done by the use of vasopresser agents. 24 In general, these agents cause changes which are the opposite of those produced by amyl nitrite. Lastly, in the clinical analysis of the problem of atypically localized murmurs of aortic stenosis and mitral insufficiency, one should take into consideration the many clues gained through a complete clinical evaluation. It is difficult to define the degree to which these should influence the diagnosis, but their significance in the purest sense is well known. These observations include arterial blood pressure, pulse pressure, type of pulse, roentgenographic localization of valve calcification, of specific chamber enlargement or of vascular change, electrocardiographic changes, the presence of detectable associated lesions, and many others. All of the clinical data should be considered, among which auscultation is an integral part. In summary, if one relies solely on the characteristic of location for the determination of the specific valvular origin of murmurs, gross errors will occasionally be made. Careful and thoughtful attention to detail must be exercised in order to avoid these pitfalls. REFERENCES 1.
2.
3. 4. 5.
Am. Heart J. October, 1963
Burch and Phillips
Phillips, J. H., and Burch, G. E.: Selected clues in cardiac auscultation, AM. HEART J. 63:1, 1962. Leatham, A.: Short communications. A classification of systolic murmurs. Proc. British Cardiac Society, Brit. Heart J. 17:.574, 1955. Leatham, A.: Systolic murmurs, Circulation 17:601, 1958. Shabetai, R., and Marshall, W. J.: Systolic murmurs, AM. HEART J. 65:412, 1963. Bergeron, J., Abelman, W. H., Vazquez-Milan, H., and Ellis, L. B.: Aortic stenosis. Clinical
6. 7.
8.
9.
10.
11.
12.
13.
14.
1.5.
16. 17.
18.
19.
20.
21.
22.
23.
24.
manifestations and course of the disease. Review of 100 proved cases, A.M.A. Arch. Int. Med. 94:911, 1954. Leatham, A.: The phonocardiogram of aortic stenosis, Brit. Heart J. 13:153, 1951. Henke, R. P., March, H. W., and Hultgren, H. N.: An aid to identification of the murmur of aortic stenosis with atypical location, XIII. HEART J. 60:354, 1960. Humphries, J., and McKusick, V.: The differentiation of organic and “innocent” systolic murmurs, Prog. Cardiovas. Dis. 5:152, 1962. Cardiovascular sound in McKusick, V. 4.: health and disease, Baltimore, 1958, Williams & Wilkins Company. Movitt, E., and Gerstl, B.: Pure mitral insufliciency of rheumatic origin in adults, Ann. Int. Med. 38:981, 1953. Edwards, J. E., and Burchell, H. B.: Endocardial and intimal lesions (jet impact) as possible sites of origin of murmurs, Circulation 18:946, 1958. Perloff, J. K., and Harvey, W. I’.: Auscultatory and phonocardiographic manifestations of pure mitral regurgitation, Prog. Cardiovas. Dis. 5:172, 1962. Osmundson, P. J., Callahan, J. A., and Edwards, J. E.: Mitral insuffi&ency from ruptured chordae tendineae simulating aortic stenosis, hoc. Staff. Meet. Mayo Clin. 33:235, 1958. R. J.: Mitral insufMiller, R., and Rearson, ficiency simulating aortic stenosis, New England I. Med. 260:1210. 1959. Shapiro, H. A., and Weiss, D. R.: Mitral insufficiency due to ruptured chordae tendineae simulating aortic stenosis, New England J. Med. 261:272, 1959. Case Records of the Massachusetts General Hospital, New England J. Med. 267:1033, 1962. Sleeper, J. C., Oigain, E. S., and McIntosh, H. D.: Mitral insufficiencv simulating aortic stenosis, Circulation 26:428: 1962. Leatham, A.: The place of phonocardiography in clinical cardiology, Prog. Cardiovas. Dis. 2:76, 1959. Burch, G. E., De Pasquale, N. P., and Phillips, J. H.: Clinical manifestations of papillary muscle dysfunction, A.M.A. Arch. Int. Med. 112:112, 1963. Phillips, J. I-I., Burch, G. E., and De Pasquale, N. I’.: The syndrome of papillary muscle dysfunction; its clinical recognition, Ann. Int. Med. (Submitted for publication.) Phillips, J. H., De Pasquale, N. P., and Burch, G. E.: The electrocardiogram in infarction of the anterolateral papillary muscle, AM. HEART J. 66:338, 1963. Perloff, J. Ii., and Harvey, W. P.: Mechanisms of fixed splitting of the second heart sound, Circulation 18:998, 19.58. Vogelpoel. L.. and Srhire, V.: The use of amyl nitrite in the diagnosis of systolic murmurs, Lancet 2:810, 1959. Endrys, J., and Bartova, A.: Pharmacologic methods in the phonocardiographic diagnosis of regurgitant murmurs, Brit. Heart J. 24:207, 1962.