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Systolic clicks and murmurs
Letters to the Editor
Systolic clicks and murmurs To the Editor: Dr. Haas I has attributed the decrease a n d / o r diappearance of midsystolic click, late systolic murmur (MSC-LSM) in the third trimester of pregnancy to decreased peripheral vascular resistance. However, the most typical response of the MSCLSM to decrease in peripheral vascular resistance is for the systolic murmur to occupy more of systole and for the systolic click to move earlier in systole.~ I have observed these auscultatory changes in a 25-year-old female during the second and third trimester of pregnancy which were associated with increase as compared to pre-pregnancy in left ventricular end-systolic and end-diastolic diameters determined by echocardiography. There was also a marked decrease in her awareness of palpitations and in the frequency of clinically observed atrial and ventricular extrasystoles, but there were no observable changes in the duration or extent of the mitral valve prolapse by echocardiography. These observations suggest increase in blood volume as the likely cause of changes in pregnancy in MSC-LSM. It is also mentioned that non-invasive clinical maneuvers can indicate "the changes in volume of mitral regurgitation." The presence or intensity or duration of systolic murmurs are not reliable guides to the extent of or even the presence of angiographically determined mitral insufficiency.~ These comments do not detract from the pertinence of the author's observations or his conclusions regarding clinical management of these patients during pregnancy.
Lewis Sasse, M.D., F.A.C.C. Southern California Parmanente Medical Group Sunset Blvd. & Edgemont St. Los Angeles, Calif. 90027
REFERENCES Haas, J. M.: The effect of pregnancy on the midsystolic click and murmur of the prolapsing posterior leaflet of the mitral valve, AM. HEART J. 92:407, 1976. 2. Popp, R. L., and Winkley, R. A.: Mitral valve prolapse syndrome, J.A.M.A. 236:867, 1976. 1.
Reply To the Editor: I wish to thank Dr. Sasse for his letter concerning my article, "The effect of pregnancy on the midsystolic click and murmur of the prolapsing posterior leaflet of the mitral valve," which appeared in the September, 1976, issue of AMERICAN HEART JOURNAL. Dr. Sasse has apparently interpreted the article to imply that the decrease and/or disappearance of the midsystolic click, late systolic murmur, in the third trimester of pregnancy, is due completely to a decrease in peripheral vascular resistance. I agree with Dr. Sasse as to the change in the intensity of the murmur and the shift of the midsystolic click to early systole with a decrease in peripheral vascular resistance alone. If one reads the article completely, he will see that our interpretation for the auscultatory phenomenon and
A m e r i c a n Hea r t J o u r n a l
its change in pregnancy is related to a combination of increase in blood volume that occurs with gestation which probably realigns the mitral valve apparatus by increasing the left ventricular end-diastolic volume and the long axis of the left ventricle, together with a reduction in peripheral vascular resistance. Perhaps the change in volume is the more important of the two?
John M. Haas, M.D. Colonel, MC Chief, Cardiology Service Fitzsimons Army Medical Center Denver, Colo. 80240
Survival of elderly patients after pacemaker implant To the Editor: In the April, 1976, issue of AMERICAN HEART JOURNAL, Dr. Amikam and co-workers1 report on favorable long-term follow-up survival rates in elderly patients with a permanent cardiac pacemaker implanted at an age of more than 70 years. Emphasizing the beneficial effects of pacemaker implantation in this age group in terms of prolongation of life and improvement of its quality, the authors point out that this aspect of pacemaker therapy has so far been paid little attention in the literature. In this context we should like to refer to our results on a series of 1,208 pacemaker patients. ~":~ Although the cumulative survival rate was slightly less favorable in the patient group as a whole as well as in the elderly subjects than the corresponding figures of the cited study,' the relative survival rate {ratio of the actual and the expected survival rate of the same age group in the general population) in patients beyond 80 years of age was found to be higher than in the age groups of 60 to 80 years after 2 years of follow-up. Taking into account that, according to the results of a questionnaire, a high percentage of previously disabled patients were capable of looking after themselves and their households after having a pacemaker implanted, 4 we can confirm the justification of permanent cardiac pacing even at a very advanced age.
Gerd Rettig, M.D. Peter Doenecke, M.D. Hermann Schieffer, M.D. Ludwig Bette, M.D. Medizinische Universitgttsklinik und Poliklinik Innere Medizin IIl D-6650 Homburg/Saar West Germany
REFERENCES 1. Amikam, S., Lemer, J., Roguin, N., Peleg, H., and Riss, E.: Long-term survival of elderly patients after pacemaker implantation, AM. HEART J. 91:445, 1976. 2. Rettig, G., Schieffer, H., Doenecke, P., F16thner, R., Drews, H., and Bette, L.: Langzeitprognose bei Schrittmacher-patienten, Herz. Kreisl. 7:497, 1975. 3. Rettig, G., Bette, L., Doenecke, P., Hoffmann, W., Schief-
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Systolic clicks and murmurs To the Editor: Dr. Haas I has attributed the decrease a n d / o r diappearance of midsystolic click, late systolic murmur (MSC-LSM) in the third trimester of pregnancy to decreased peripheral vascular resistance. However, the most typical response of the MSCLSM to decrease in peripheral vascular resistance is for the systolic murmur to occupy more of systole and for the systolic click to move earlier in systole.~ I have observed these auscultatory changes in a 25-year-old female during the second and third trimester of pregnancy which were associated with increase as compared to pre-pregnancy in left ventricular end-systolic and end-diastolic diameters determined by echocardiography. There was also a marked decrease in her awareness of palpitations and in the frequency of clinically observed atrial and ventricular extrasystoles, but there were no observable changes in the duration or extent of the mitral valve prolapse by echocardiography. These observations suggest increase in blood volume as the likely cause of changes in pregnancy in MSC-LSM. It is also mentioned that non-invasive clinical maneuvers can indicate "the changes in volume of mitral regurgitation." The presence or intensity or duration of systolic murmurs are not reliable guides to the extent of or even the presence of angiographically determined mitral insufficiency.~ These comments do not detract from the pertinence of the author's observations or his conclusions regarding clinical management of these patients during pregnancy.
Lewis Sasse, M.D., F.A.C.C. Southern California Parmanente Medical Group Sunset Blvd. & Edgemont St. Los Angeles, Calif. 90027
REFERENCES Haas, J. M.: The effect of pregnancy on the midsystolic click and murmur of the prolapsing posterior leaflet of the mitral valve, AM. HEART J. 92:407, 1976. 2. Popp, R. L., and Winkley, R. A.: Mitral valve prolapse syndrome, J.A.M.A. 236:867, 1976. 1.
Reply To the Editor: I wish to thank Dr. Sasse for his letter concerning my article, "The effect of pregnancy on the midsystolic click and murmur of the prolapsing posterior leaflet of the mitral valve," which appeared in the September, 1976, issue of AMERICAN HEART JOURNAL. Dr. Sasse has apparently interpreted the article to imply that the decrease and/or disappearance of the midsystolic click, late systolic murmur, in the third trimester of pregnancy, is due completely to a decrease in peripheral vascular resistance. I agree with Dr. Sasse as to the change in the intensity of the murmur and the shift of the midsystolic click to early systole with a decrease in peripheral vascular resistance alone. If one reads the article completely, he will see that our interpretation for the auscultatory phenomenon and
A m e r i c a n Hea r t J o u r n a l
its change in pregnancy is related to a combination of increase in blood volume that occurs with gestation which probably realigns the mitral valve apparatus by increasing the left ventricular end-diastolic volume and the long axis of the left ventricle, together with a reduction in peripheral vascular resistance. Perhaps the change in volume is the more important of the two?
John M. Haas, M.D. Colonel, MC Chief, Cardiology Service Fitzsimons Army Medical Center Denver, Colo. 80240
Survival of elderly patients after pacemaker implant To the Editor: In the April, 1976, issue of AMERICAN HEART JOURNAL, Dr. Amikam and co-workers1 report on favorable long-term follow-up survival rates in elderly patients with a permanent cardiac pacemaker implanted at an age of more than 70 years. Emphasizing the beneficial effects of pacemaker implantation in this age group in terms of prolongation of life and improvement of its quality, the authors point out that this aspect of pacemaker therapy has so far been paid little attention in the literature. In this context we should like to refer to our results on a series of 1,208 pacemaker patients. ~":~ Although the cumulative survival rate was slightly less favorable in the patient group as a whole as well as in the elderly subjects than the corresponding figures of the cited study,' the relative survival rate {ratio of the actual and the expected survival rate of the same age group in the general population) in patients beyond 80 years of age was found to be higher than in the age groups of 60 to 80 years after 2 years of follow-up. Taking into account that, according to the results of a questionnaire, a high percentage of previously disabled patients were capable of looking after themselves and their households after having a pacemaker implanted, 4 we can confirm the justification of permanent cardiac pacing even at a very advanced age.
Gerd Rettig, M.D. Peter Doenecke, M.D. Hermann Schieffer, M.D. Ludwig Bette, M.D. Medizinische Universitgttsklinik und Poliklinik Innere Medizin IIl D-6650 Homburg/Saar West Germany
REFERENCES 1. Amikam, S., Lemer, J., Roguin, N., Peleg, H., and Riss, E.: Long-term survival of elderly patients after pacemaker implantation, AM. HEART J. 91:445, 1976. 2. Rettig, G., Schieffer, H., Doenecke, P., F16thner, R., Drews, H., and Bette, L.: Langzeitprognose bei Schrittmacher-patienten, Herz. Kreisl. 7:497, 1975. 3. Rettig, G., Bette, L., Doenecke, P., Hoffmann, W., Schief-
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