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Musical Murmur and Cardiac Shudder
by Shapiro et al," both cr of the thorax and 13II-MIBG scanning were able to locate the tumor within the mediastinum, but the precise anatomic relationships of the tumor to the aorta, pulmonary artery, and the left atrium in our case were established only after two-dimensional echocardiography utilizing the suprasternal approach. While the presence of a mass in this location, as detected by two-dimensional echocardiography, cannot be considered specific for paraganglioma, clinical suspicion should be aroused in patients with hypertension or those with known pheochromocytoma. Since the aortic arch and the aorticopulmonary region can be satisfactorily imaged by suprasternal two-dimensional eehocardiography," the latter technique may be a useful adjunct to cr and MIBG scanning in the diagnosis of aorticopulmonary tumors. In addition, standard precordial and subcostal echocardiographic approaches may detect other cardiac abnormalities associated with pheochromocytoma and are useful in assessing left ventricular size, wall thickness, and function. In summary, two-dimensional echocardiography, utilizing the suprasternal approach, can detect and localize the rare pheochromocytoma that involves the middle mediastinum . Although our experience with the imaging of mediastinal abnormalities (for example, lymph nodes), utilizing this technique, has thus far been limited, it is likely that other aorticopulmonary tumors will be visualized by this technique as well. REFERENCES 1 Cueto L, Arriaga J, Zinser J. Echocardiographic changes in pheochromocytoma. Chest 1979; 76:600-01 2 Peiper H-J. Golestan C . Intrathorakales phaochromozytom. Thoraxchirurgie 1963: 10:517-26 3 Shapiro B, Sisson J. KalffV, Glowniak J, Satterle W, Glazer G, et al. The location of middle mediastinal pheochromocytomas. J Thorac Cardiovasc Surg 1984: 87:814-20 4 Hodgson SF, Sheps SG. Subramanian R, Lie IT. Carney JA. Catecholamine secreting paraganglioma of the interatrial septum. Am J Med 1984; 77:157-61 5 Saad MF, Frazier OH, Hickey RC, Samaan NA. Intrapericardial pheochromocytoma. Am J Med 1983:75:371-76 6 'Dljik AJ, Seward JB, Hagler OJ, Mair DO, Lie IT. Two-dimensional real-time ultrasonic imaging of the heart and great vessels : technique, image orientation, structure, identification, and validation. Mayo Clin Proc 1978: 53:271-303
Musical Murmur and cardiac Shudder*
musical cardiac murmur displays pure frequencies on A phonocardiograms, and a cardiac structure tound vibrat-
ing, during concomitant echocardiographic studies, at a similar basic frequency, may be assumed to be the origin of the murmur. J.J Occasionally, more than one structure in the path of conduction of the sound may vibrate prominently, as reported herein . In such a situation, we found that the abnormal structure, presumably the murmurs origin, vibrated with the largest amplitude. CASE REPORT Following acute rheumatic carditis, a 17-year-old youth developed the usual murmur of aortic regurgitation. In the ensuing months, efIOrt tolerance worsened, and the heart dilated progressively. A year later, the diastolic murmur became musical and intense (grade 616), with an associated precordial thrill. In Figure 1, the phonocardiogram recorded in Eros area shows a diastolic murmur with two tonal shades corresponding, on close examination, to two pure frequencies, 90 and 180 Hz. Evidently, the fundamental frequency is 90 Hz, and the higher frequency is its harmonic overtone. Figure 2. A to C, shows M-mode echocardiograms at the aortic valve, mitral valve, and midventricular level, respectively, with simultaneous phonocardiographic recordings. The aortic valvular cusps, aortic walls, anterior mitral leaflet, basal interventricular septum, and midventricular walls show concerted, rhythmic diastolic vibrations at 80 to 90 Hz, diminishing in amplitude &om the aortic valve outwards. Their vibratory frequency corresponds to the fundamental phonocardiographic frequency. At cardiac catheterization, severe aortic regurgitation was confirmed on aortographic studies. In the left ventricular diastolic pressure tracing shown in Figure 3, regular oscillations of pressure tapering &om early diastole are observed, again at a frequency of about 90 Hz. During surgery lOr valvular replacement, the surgeon reported a shuddering thrill while handling the heart. For practical reasons, this was not graphically recorded. The excised aortic cusps, retracted and fibrotic, had retroverted margins.
DISCUSSION
Whether valvular vibrations are primary or secondary events in the production of musical murmurs is uncertain. Nevertheless, the presence of a valvular flutter similar in frequency to the murmur is believed to help in localizingthe site of the abnormality." however, when the vibrations are gross, more than one structure in the cardiobemic unit may vibrate concordantly, as exemplified by our patient. 4 'Ib localize the murmur in this uncommon situation, it is logical
iii III ii iii iii IIi iIII i iIII iii IIi i iii iii IIiii IIfilii filii i iii' i iiii ii iii
Maurice H. Choo, M.D ., F.C.C .P.; P. K. Mah, M.D. ; B. L. Chla, M.D ., F.C.C.P.; N. C. Tan, M.D .; and L. M. Cho, M.B.
When echocardiographic studies show several structures vibrating at a similar frequency to an associated musical cardiac murmur, the structure vibrating most strongly may localize the origin of the murmur. *From the University Department of Medicine (II), Singapore General Hospital, Singapore. Reprint requests: Dr: Choo , University Department of Medicine, Singapore General Hospital , Singapore, Republic of Singapore
838
FIGURE 1. Recorded in third left interspace, phonocardiogram shows diastolic murmur (OM) with two pure frequencies.
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FIGURE 2. A (left), M-mode echocardiogram at aortic valvular level, showing diastolic 8uttering (arT0W8)of aortic cusps and walls in diastole. Largest vibratory amplitude is observed in aortic cusps . B (center), M-mode echocardiogram at mitral valvular level, showing diastolic 8uttering (arrows) of anterior mitral leaflet and basa1 interventricular septum. C (right). M-mode echocardiogram at midventricular level, showing diastolic fluttering (arT0W8) of interventricular septum and left ventricular posterior wall, in which fluttering is noted after nadir of septal echo and peak ofT wave. an echophonocardiographic study. Am J Cardiol 1978; 41:952-55 2 Chia BL. Chao MH, WolffC, Craige E. Phonoechocardiography in tricuspid "honks." Am Heart J 1984; 107:1032-34 3 Stein PO , Sabbah HN , Magilligan OJ. Lakier }B. Mechanism of musical systolic murmur caused by a degenerated porcine bloprosthetic valve (abstract). Circulation 1981: 64:IV-29 4 Rushmer RF. Cardiovascular dynamics. Philadelphia: WB Saunders. 1976:431-34 5 Sabbah HN. Stein PD . Investigation of the theory and mechanism of the origin of the second heart sound. Circ Res 1976: 39:874-82
Zeolite Exposure and Associated Pneumoconiosis·
Kenneth R. CMey. M.D., F.C.C.P. ;]ohn w Shlgeolw . M.D.; William N. Rom, M.D.• M.P.H.• F.C .C.P.; and Farhad Moatamed. M.D.
Naturally occurring zeolite minerals are aluminum silicates widespread in the earths crust. Several of these minerals have 6brous forms and have been implicated as a possible cause of benign and malignant diseases of the lung and pleura in Thrkey. This report describes a patient, living in an area of Nevada rich in zeolites, who presented with idiopathic pleural thickening and pulmonary 6brosis associated with extensive pulmonary deposition of zeolites. FIGURE 3. Left ventricular pressure recording. showing regular oscillations (arrow) of diastolic pressures.
to identify the structure with the maximum vibratory amplitude (in our case, the aortic cusps). Other features, clinical and echocardiographic, may be used for confirmation. The isorhythmic pressure oscillationswe describe are also rarely recorded. They clearly substantiate in vitro experiments that attribute the production of sound to alternate compression and rarefaction of blood adjacent to vibrating valves." REFERENCES
1 Venkataraman K, Siegel R. Kim SJ. Allen Jw. Musical murmurs:
to a number of silicate minerals has been E xposure associated with pneumoconioses. Zeolites are a group
of approximately 40 aluminum silicate minerals, of which some, such as erionite and mordenite, have fibrous forms. I Some of the richest zeolite deposits in the world are located in the western United States, particularly in Nevada and Utah. Zeolites, especiallyerionite, have been implicated as an etiologic factor in an outbreak of benign and malignant ·From the Veterans Administration Medical Center, Electron Microscopy Laboratory, Rocky Mountain Center for Occupational and Environmental Health, and the Departments of Medicine, Pathology, and Family Community Medicine, University of Utah School of Medicine, Salt Lake City. Supported in part by the Veterans Administration. Manuscript received August 6: revision accepted November 21.
Reprint requests: Dr. CG.fey, University of Utah Medical Center.50 North Medical Drive. Salt Lake City 84132 CHEST I 87 I 6 I JUNE, 1965
837
Musical Murmur and cardiac Shudder*
musical cardiac murmur displays pure frequencies on A phonocardiograms, and a cardiac structure tound vibrat-
ing, during concomitant echocardiographic studies, at a similar basic frequency, may be assumed to be the origin of the murmur. J.J Occasionally, more than one structure in the path of conduction of the sound may vibrate prominently, as reported herein . In such a situation, we found that the abnormal structure, presumably the murmurs origin, vibrated with the largest amplitude. CASE REPORT Following acute rheumatic carditis, a 17-year-old youth developed the usual murmur of aortic regurgitation. In the ensuing months, efIOrt tolerance worsened, and the heart dilated progressively. A year later, the diastolic murmur became musical and intense (grade 616), with an associated precordial thrill. In Figure 1, the phonocardiogram recorded in Eros area shows a diastolic murmur with two tonal shades corresponding, on close examination, to two pure frequencies, 90 and 180 Hz. Evidently, the fundamental frequency is 90 Hz, and the higher frequency is its harmonic overtone. Figure 2. A to C, shows M-mode echocardiograms at the aortic valve, mitral valve, and midventricular level, respectively, with simultaneous phonocardiographic recordings. The aortic valvular cusps, aortic walls, anterior mitral leaflet, basal interventricular septum, and midventricular walls show concerted, rhythmic diastolic vibrations at 80 to 90 Hz, diminishing in amplitude &om the aortic valve outwards. Their vibratory frequency corresponds to the fundamental phonocardiographic frequency. At cardiac catheterization, severe aortic regurgitation was confirmed on aortographic studies. In the left ventricular diastolic pressure tracing shown in Figure 3, regular oscillations of pressure tapering &om early diastole are observed, again at a frequency of about 90 Hz. During surgery lOr valvular replacement, the surgeon reported a shuddering thrill while handling the heart. For practical reasons, this was not graphically recorded. The excised aortic cusps, retracted and fibrotic, had retroverted margins.
DISCUSSION
Whether valvular vibrations are primary or secondary events in the production of musical murmurs is uncertain. Nevertheless, the presence of a valvular flutter similar in frequency to the murmur is believed to help in localizingthe site of the abnormality." however, when the vibrations are gross, more than one structure in the cardiobemic unit may vibrate concordantly, as exemplified by our patient. 4 'Ib localize the murmur in this uncommon situation, it is logical
iii III ii iii iii IIi iIII i iIII iii IIi i iii iii IIiii IIfilii filii i iii' i iiii ii iii
Maurice H. Choo, M.D ., F.C.C .P.; P. K. Mah, M.D. ; B. L. Chla, M.D ., F.C.C.P.; N. C. Tan, M.D .; and L. M. Cho, M.B.
When echocardiographic studies show several structures vibrating at a similar frequency to an associated musical cardiac murmur, the structure vibrating most strongly may localize the origin of the murmur. *From the University Department of Medicine (II), Singapore General Hospital, Singapore. Reprint requests: Dr: Choo , University Department of Medicine, Singapore General Hospital , Singapore, Republic of Singapore
838
FIGURE 1. Recorded in third left interspace, phonocardiogram shows diastolic murmur (OM) with two pure frequencies.
11111I111I111111I1111I1111I1111I1111I 1111I1111I1111I1111I1111I11111111I1111I ~
,.'
.
_~
.. . . . . ~
Yr> ,
. -
_-
.. _ ~.
FIGURE 2. A (left), M-mode echocardiogram at aortic valvular level, showing diastolic 8uttering (arT0W8)of aortic cusps and walls in diastole. Largest vibratory amplitude is observed in aortic cusps . B (center), M-mode echocardiogram at mitral valvular level, showing diastolic 8uttering (arrows) of anterior mitral leaflet and basa1 interventricular septum. C (right). M-mode echocardiogram at midventricular level, showing diastolic fluttering (arT0W8) of interventricular septum and left ventricular posterior wall, in which fluttering is noted after nadir of septal echo and peak ofT wave. an echophonocardiographic study. Am J Cardiol 1978; 41:952-55 2 Chia BL. Chao MH, WolffC, Craige E. Phonoechocardiography in tricuspid "honks." Am Heart J 1984; 107:1032-34 3 Stein PO , Sabbah HN , Magilligan OJ. Lakier }B. Mechanism of musical systolic murmur caused by a degenerated porcine bloprosthetic valve (abstract). Circulation 1981: 64:IV-29 4 Rushmer RF. Cardiovascular dynamics. Philadelphia: WB Saunders. 1976:431-34 5 Sabbah HN. Stein PD . Investigation of the theory and mechanism of the origin of the second heart sound. Circ Res 1976: 39:874-82
Zeolite Exposure and Associated Pneumoconiosis·
Kenneth R. CMey. M.D., F.C.C.P. ;]ohn w Shlgeolw . M.D.; William N. Rom, M.D.• M.P.H.• F.C .C.P.; and Farhad Moatamed. M.D.
Naturally occurring zeolite minerals are aluminum silicates widespread in the earths crust. Several of these minerals have 6brous forms and have been implicated as a possible cause of benign and malignant diseases of the lung and pleura in Thrkey. This report describes a patient, living in an area of Nevada rich in zeolites, who presented with idiopathic pleural thickening and pulmonary 6brosis associated with extensive pulmonary deposition of zeolites. FIGURE 3. Left ventricular pressure recording. showing regular oscillations (arrow) of diastolic pressures.
to identify the structure with the maximum vibratory amplitude (in our case, the aortic cusps). Other features, clinical and echocardiographic, may be used for confirmation. The isorhythmic pressure oscillationswe describe are also rarely recorded. They clearly substantiate in vitro experiments that attribute the production of sound to alternate compression and rarefaction of blood adjacent to vibrating valves." REFERENCES
1 Venkataraman K, Siegel R. Kim SJ. Allen Jw. Musical murmurs:
to a number of silicate minerals has been E xposure associated with pneumoconioses. Zeolites are a group
of approximately 40 aluminum silicate minerals, of which some, such as erionite and mordenite, have fibrous forms. I Some of the richest zeolite deposits in the world are located in the western United States, particularly in Nevada and Utah. Zeolites, especiallyerionite, have been implicated as an etiologic factor in an outbreak of benign and malignant ·From the Veterans Administration Medical Center, Electron Microscopy Laboratory, Rocky Mountain Center for Occupational and Environmental Health, and the Departments of Medicine, Pathology, and Family Community Medicine, University of Utah School of Medicine, Salt Lake City. Supported in part by the Veterans Administration. Manuscript received August 6: revision accepted November 21.
Reprint requests: Dr. CG.fey, University of Utah Medical Center.50 North Medical Drive. Salt Lake City 84132 CHEST I 87 I 6 I JUNE, 1965
837