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Systolic Click and Late Systolic Murmur in a Young Woman
SOUND OF THE HEART Systolic Click and Late Systolic Murmur Woman·
In
a Young
Aldo A. Luisada, M.D. and Pachalla Bhat, M.D. An asymptomatic young woman with a systoHc click and late systolic murmur is discussed. Phonocardiograms, multiple cardiograms, carotid tracing, and echo-
21-year-old white woman was found to have a Aheart munnur at birth which was confirmed at
age Bve. There is no history of rheumatic fever, scarlet fever, or diphtheria, but she had chicken-pox and measles. This patient has been asymptomatic, except for episodes of palpitation caused by ectopic beats.
PE: Nonnal pulse and blood pressure. On palpation, minor intpulses were felt in the 4th and 5th intercostal spaces. Nonnal heart size by percussion. No thrills. On auscultation, the first and second heart sounds are nonnal. No fourth or third sound. There is a late systolic click followed by a late systolic munnur in crescendo, best heard in the 3rd and 4th left interspaces. ·From the Department of Medicine, The Chicago Medical School/University of Health Sciences and the Oak Forest Hospital, Oak Forest, Illinois. Reprint requests: Dr. Luisada, Oak Forest Hospital, Oak Forest, Illinois 604S2
cardiogram revealed a prolapse of the posterior mitral lea8et. Angiocardiogram confirmed the diagnosis made by use of the noninvasive methods.
ECG: Nonnal tracing, except for T wave inversion in 3 and aVF (during an episode of palpitation, numerous polyfocal ventricular ectopic beats were present). PCG: Tracings recorded in the medium-low frequency range showed a large click in late systole, preceded by several small vibrations, best recorded in the 4th and 5th ICS (Fig 1). In the high frequency range, the click became larger and a late systolic munnur became apparent between the click and the aortic component of the second sound. The third derivative of the phonocardiogram revealed the murmur best. The munnur radiated to the 3rd right ics (Fig. 2). Low Frequency Tracings: The apex cardiogram showed a trough coinciding with the click and simulating the 0 point (Fig 1). On the contrary, in the 3rd left ICS, a second peak conincided with the click. Carotid Tracing: Nonnal carotid pulse (Fig 2). Echo: An echocardiogram, recorded in the M mode, revealed that the echoes of the two leaflets of the mitral valve diverged in systole, due to drop of the posterior leaflet. X-Ray: A chest x-ray ffim showed that the heart was of nonnal size.
.~
. . . -. . .~'H~t I
II
~""~Ih\+ FIGURE 1. Phonocardiograms and low frequency tracings. PCGs are recorded with IDters at nominal frequency of 100 Hz; upper is in 4th ICS; lower is in 5th ICS. LF tracing is in 4th ICS. Note systolic click (c) and small third sound ( III ). Trough of LF tracing coincides with click.
292 LUISADA, BHAY
FIGURE 2. Phonocardiograms and carotid tracing. PCGs are recorded with IDters at nominal frequency of 100 Hz over 3rd right (upper) and the 3rd left ICS (lower tracing). These tracings reveal actual position of aortic component of second sound (IIA). In previous tracing, click could have been misinterpreted for it.
CHEST, 66: 3, SEPTEMBER, 1974
Cardiac Catheterization and Angiography: These procedures had been previously performed at St. Catherine Hospital but the report reached us after completion of our study. All pressures were found normal in both the right and left heart chambers and vessels. Injection of radiopaque material into the left ventricle revealed: (a) prolapse of the posterior mitral leaflet; (b) minimal mitral insufficiency; and ( c ) abnormal left ventricular contraction (flopping of the wall). DISCUSSION
The findings of this case coincide with previous reports by Segal and Likoff, l Hancock and Cohn,1I Kesteloot and Van Houte,8 William et aI,' Kerber et aI,II and Spencer et aI. 6 The demonstration of (1) click and systolic murmur by phonocardiography; (2) abnormal low frequency tracings; and (3) echocardiographic evidence of the posterior mitral leaflet drop in systole would have led to a correct diagnosis even without
cardiac catheterization and angiography. However, confirmation by "invasive" techniques confirmed the results of our findings.
1 Segal BL, Likoff W: Late systolic murmur of mitral regurgitation. Am Heart J frl:757-763, 1964 2 Hancock EW, Cohn K: The syndrome associated with midsystolic click and late systolic murmur. Am J Med 41:183-196,1966 3 Kesteloot H, Van Houte 0: On the origin of the telesystolic murmur preceded by a click. Acta Cardiol (Brux) 20:197209,1965 . . 4 Williams J, Raelandt J, et al: Late systolic murmur and systolic nonejection clicks. Acta Cardiol (Brux) 24:456-
481, 1969
5 Kerber RE, et al: Echocardiographic patterns in patients with the syndrome of systolic click and late systolic murmur. N Eng} J Med 284:691-693, 1971 6 Spencer WH, et al: Apex cardiogram in patients with prolapsing mitral valve. Am J Cardiol 32:276-282, 1973
The Charm and Beauty of Azaleas From all the plants of the past, there have evolved few flowering shrubs offering more facets of loveliness and, wisely selected greater adaptability to diverse climatic conditions than the azaleas. This is no inconsiderable claim when we realize the tiny niche that the seventy or so species occupy in the evolution of the great number, perhaps 225 thousand, of present-day species of other flowering plants. The flowers of azaleas have a remarkable color range-white and yellow, orange, scarlet, crimson, and purple, with an array of intermediate hues of various intensities. There are vivid and sparkling shades, pastel tints, pure whites, and striped, flecked, or sectored designs, as well as self-colored flowers with or
CHEST, 66: 3, SEPTEMBER, 1974
without contrasting throats or blotches (eyes). Altogether there are about seventy species and 4,800 named cultivated varieties. Azaleas are long-lived plants, and their beauty increases with size and age. Like certain people, they grow old gracefully. Plants growing in the Arnold Arboretum near Boston, Massachusetts, are fifty to seventy-five years old, and they are still flourishing. Some of the Southern Indian Azaleas, now on display at Magnolia Gardens near Charleston, North Carolina, were planted a century ago. Lee FP: The Azalea Book. Princeton, New Jersey, D Van Norstrand, 1958
SYSTOLIC CLICK AND LATE SYSTOLIC MURMUR 293
In
a Young
Aldo A. Luisada, M.D. and Pachalla Bhat, M.D. An asymptomatic young woman with a systoHc click and late systolic murmur is discussed. Phonocardiograms, multiple cardiograms, carotid tracing, and echo-
21-year-old white woman was found to have a Aheart munnur at birth which was confirmed at
age Bve. There is no history of rheumatic fever, scarlet fever, or diphtheria, but she had chicken-pox and measles. This patient has been asymptomatic, except for episodes of palpitation caused by ectopic beats.
PE: Nonnal pulse and blood pressure. On palpation, minor intpulses were felt in the 4th and 5th intercostal spaces. Nonnal heart size by percussion. No thrills. On auscultation, the first and second heart sounds are nonnal. No fourth or third sound. There is a late systolic click followed by a late systolic munnur in crescendo, best heard in the 3rd and 4th left interspaces. ·From the Department of Medicine, The Chicago Medical School/University of Health Sciences and the Oak Forest Hospital, Oak Forest, Illinois. Reprint requests: Dr. Luisada, Oak Forest Hospital, Oak Forest, Illinois 604S2
cardiogram revealed a prolapse of the posterior mitral lea8et. Angiocardiogram confirmed the diagnosis made by use of the noninvasive methods.
ECG: Nonnal tracing, except for T wave inversion in 3 and aVF (during an episode of palpitation, numerous polyfocal ventricular ectopic beats were present). PCG: Tracings recorded in the medium-low frequency range showed a large click in late systole, preceded by several small vibrations, best recorded in the 4th and 5th ICS (Fig 1). In the high frequency range, the click became larger and a late systolic munnur became apparent between the click and the aortic component of the second sound. The third derivative of the phonocardiogram revealed the murmur best. The munnur radiated to the 3rd right ics (Fig. 2). Low Frequency Tracings: The apex cardiogram showed a trough coinciding with the click and simulating the 0 point (Fig 1). On the contrary, in the 3rd left ICS, a second peak conincided with the click. Carotid Tracing: Nonnal carotid pulse (Fig 2). Echo: An echocardiogram, recorded in the M mode, revealed that the echoes of the two leaflets of the mitral valve diverged in systole, due to drop of the posterior leaflet. X-Ray: A chest x-ray ffim showed that the heart was of nonnal size.
.~
. . . -. . .~'H~t I
II
~""~Ih\+ FIGURE 1. Phonocardiograms and low frequency tracings. PCGs are recorded with IDters at nominal frequency of 100 Hz; upper is in 4th ICS; lower is in 5th ICS. LF tracing is in 4th ICS. Note systolic click (c) and small third sound ( III ). Trough of LF tracing coincides with click.
292 LUISADA, BHAY
FIGURE 2. Phonocardiograms and carotid tracing. PCGs are recorded with IDters at nominal frequency of 100 Hz over 3rd right (upper) and the 3rd left ICS (lower tracing). These tracings reveal actual position of aortic component of second sound (IIA). In previous tracing, click could have been misinterpreted for it.
CHEST, 66: 3, SEPTEMBER, 1974
Cardiac Catheterization and Angiography: These procedures had been previously performed at St. Catherine Hospital but the report reached us after completion of our study. All pressures were found normal in both the right and left heart chambers and vessels. Injection of radiopaque material into the left ventricle revealed: (a) prolapse of the posterior mitral leaflet; (b) minimal mitral insufficiency; and ( c ) abnormal left ventricular contraction (flopping of the wall). DISCUSSION
The findings of this case coincide with previous reports by Segal and Likoff, l Hancock and Cohn,1I Kesteloot and Van Houte,8 William et aI,' Kerber et aI,II and Spencer et aI. 6 The demonstration of (1) click and systolic murmur by phonocardiography; (2) abnormal low frequency tracings; and (3) echocardiographic evidence of the posterior mitral leaflet drop in systole would have led to a correct diagnosis even without
cardiac catheterization and angiography. However, confirmation by "invasive" techniques confirmed the results of our findings.
1 Segal BL, Likoff W: Late systolic murmur of mitral regurgitation. Am Heart J frl:757-763, 1964 2 Hancock EW, Cohn K: The syndrome associated with midsystolic click and late systolic murmur. Am J Med 41:183-196,1966 3 Kesteloot H, Van Houte 0: On the origin of the telesystolic murmur preceded by a click. Acta Cardiol (Brux) 20:197209,1965 . . 4 Williams J, Raelandt J, et al: Late systolic murmur and systolic nonejection clicks. Acta Cardiol (Brux) 24:456-
481, 1969
5 Kerber RE, et al: Echocardiographic patterns in patients with the syndrome of systolic click and late systolic murmur. N Eng} J Med 284:691-693, 1971 6 Spencer WH, et al: Apex cardiogram in patients with prolapsing mitral valve. Am J Cardiol 32:276-282, 1973
The Charm and Beauty of Azaleas From all the plants of the past, there have evolved few flowering shrubs offering more facets of loveliness and, wisely selected greater adaptability to diverse climatic conditions than the azaleas. This is no inconsiderable claim when we realize the tiny niche that the seventy or so species occupy in the evolution of the great number, perhaps 225 thousand, of present-day species of other flowering plants. The flowers of azaleas have a remarkable color range-white and yellow, orange, scarlet, crimson, and purple, with an array of intermediate hues of various intensities. There are vivid and sparkling shades, pastel tints, pure whites, and striped, flecked, or sectored designs, as well as self-colored flowers with or
CHEST, 66: 3, SEPTEMBER, 1974
without contrasting throats or blotches (eyes). Altogether there are about seventy species and 4,800 named cultivated varieties. Azaleas are long-lived plants, and their beauty increases with size and age. Like certain people, they grow old gracefully. Plants growing in the Arnold Arboretum near Boston, Massachusetts, are fifty to seventy-five years old, and they are still flourishing. Some of the Southern Indian Azaleas, now on display at Magnolia Gardens near Charleston, North Carolina, were planted a century ago. Lee FP: The Azalea Book. Princeton, New Jersey, D Van Norstrand, 1958
SYSTOLIC CLICK AND LATE SYSTOLIC MURMUR 293