The murmur of mitral stenosis; modification by A-V dissociation∗

Case Reports The Murmur Modification M.~RVIN A.

SACKNER,

M.D.,

of Mitral

by A-V Dissociation* DORIS SOMERSON, V.D. and SAhIUEL BELLET, Philadelphia,

Urinalysis and hematologic Laboratory Data: examination were normal. Blood cultures were sterile. The sedimentation rate (M’entrobe) was 40 mm. in one hour. The antihyaluronidase titer was greater than 1,024 and the antistreptolysin titer was 512. Serum glutamic oxaloacetic transaminase The circulation time; arm to tongue, was 48 units. was 12 seconds. arm to lung, 4 seconds. Chest roentgenograms showed straightening of the left border of the heart and an enlarged left atrium.

HE

CASE REPORT D. W., a thirty-seven year old Negro woman, was admitted to the Philadelphia General Hospital because of easy fatiguability, palpitation and painful swelling of the fingers and ankles of t\vo weeks’ dura-

The clinical diagnosis Clinicul Diagnosis: rheumatic heart disease, mitral stenosis, acute matic carditis, A-V dissociation.

tion. Past history revealed rheumatic fever at the age of sixteen >-ears: a normal pregnancy at twenty-four and a transient attack of pain in the left side of the chest, palpitation and hemoptysis at thirty-three A chest roentgrnogram taken at the time of years. employment eighteen months prior to admission showed cardiac enlargement.

DECEMBER

the Division 1959

of Cardiology,

Philadelphia

was rheu-

The arthralgia responded to salicylate Course: therapy. ‘I’he sedimentation rate, antistrrptolysin and antihyaluronidase titers remained moderately elevated after a month, at which time the patient was discharged to convalesce at home.

Physical Euumination: The patient was a slightly obese woman who did not appear acutely ill. The pulse was 80 per minute, rhythm was irregular, the blood pressure 110/70 mm. Hg, respiration 20 per minute and temperature 99’F. No objective joint manifestations were observed. The jugular veins were not abnormally distended. The lung fields were clear. The heart was slightly enlarged to the left by percussion. .2 diastolic thrill was present at the apex. A regular cardiac rhythm was interrupted by periods of irregularity. At the apex, during the long cycles, an accentuated first heart sound, an opening snap and a pandiastolic rumble were heard. In addition, during the short cardiac cycles, a loud presystolic rumble was present. A soft early systolic “flow” murmur was heard at the base. The liver was normal in size and no peripheral edema was noted. * From

M.D., F.A.C.C.

Pennsylvania

purpose of this report is to describe some interesting modifications of the auscultatory phenomenon resulting from A-V dissociation, in a patient with mitral stenosis.

T

Stenosis;

Elrctrocardiograms (Fig. 7): The configuration of the QRS and T were normal, hut the P wave; were notched in leads I, II, a\‘F and Y:! to L-6. There was sinus arrhythmia and nodal escapes after long P-P inter\pals leading to isorhvthmic A-V dissociation. In some beats, the ‘nodal pacemaker completely controlled the heart (retrograde P wa\.es latxlcd P’), while in others there were fusion beats in the atrium (lahelcd P”). This arrh)-thmia disappeared after the second day, and upon discharge from the hospital one month later, sinus bradycardia was present. Phonorardiogmnu

General 821

Hospital,

Philadelphia,

(Figs.

2, .3 and -i):

Pennsylvania.

The

first

822

Sackner,

Somerson

and Bellet

heart sound was delayed. At the apex, an opening snap followed by a diastolic rumble was recorded. .4 loud presystolic rumble was recorded only- when the P wave was conducted and not during periods of .4-V dissociation when the P wave overtook the QRS complex or during lower nodal rhythm. On succeeding days, as the rhythm returned to normal sinus, the presystolic rumble was present with every cardiac cycle. The intensity of the diastolic rumble decreased as cardiac rate slowed. The opening snap was loudest at the third interspace to the left of the sternum. The Valsalva maneuver caused the physiologic split second sound to fuse and the 2-0s distance to lengthen or remain unchanged. Following the tcrmination of the maneuver with inspiration. the physiologic split second sound widened and the 2-0s distance shortened or remained the same. The \.alsalva maneuver decreased the intensity, while inspiration increased the intensity of the pulmonary systolic murmur. Tracing (f;ig. 5): This showed a JUph normal pattern during sinus rhythm. However, during A-V dissociation the a wave merged with the c wave. LYhen the a wave occurred after the first heart sound, no presystolic ruml)le occurred. Carotid corded.

Tracing:

A normal

contour

was re-

ilpex Cardiogram: The opening snap was recorded between the wave responsible for atrioventricular valve closure and that for rapid ventricular filling. COMMENT This case clearly shows, as is generally accepted, that atria1 ejection of blood into the ventricle prior to ventricular systole is responsible for the presystolic rumble in mitral stenosis. The presence of A-V dissociation affords an opportunity to observe graphically the variations in the auscultatory phenomenon. The Valsalva maneuver is of value in separating the opening snap from a physiologic split Normally, the aortic valve second sound. closure component of the second sound precedes the pulmonic valve closure component. The Valsalva maneuver diminishes venous return and increases the flow of blood from the lungs to the left side of the heart. Thus, left ventricular systole is prolonged and right venTHE

AMERICAN

JOURNAL

OF

CARDIOLOGY

Mitral

Stenosis

823

DAY I

DAY 2

DAY 3

FIG. 2. Phonocardiograms recorded at tracings.) 1 = first heart sound; 2 = prcsystolic rumble. The opening snap with the slwrter cycles. The presystolic

25 mm./second on days I, 2 and 3. CA11 phonocardiograms are logarithmic second heart sound: OS = opening snap; DR = diastolic rumble; PR = occurs in every cardiac cycle. The intensity of the diastolic rumble incrrases rumble is heard only when there is a normal PR distance.

DAY4

FIG. 3. DECEMBER

1953

Phonocardiograms

recorded

at 75 mm./second

on days 1, 2 and 4.

824

Sackner,

Somerson

and Bellet

DAY I

FIG. 4. Phonocardiogram recorded at 75 mm./sccond Value of Valsalva maneuver in distinguishing opening snap. 1 = first heart sound ; 2 = second heart sound; 2 ’ = pulmonic component of second hrart sound; Shb = systolic murmur. The Valsalva manruver causes the physiologic split of the second sonnd to fnsc and clearly separatrs

the opening snap. Inspiration following the termination of this tnaneuvrr causes widening of thr physiologic split second sound and merger with the opening snap. In the lower tracing of the pulmonic area, the Valsalva mancnvcr diminishes the intensity of the systolic mnrmnr while inspiration increases it, indicating that it probably oriqinatrs from the pulmonic valor

FIG. 5.

Jugular

pulse tracing

the n wave overtakrs

tricular

systole

the

second

the

opening

component

shortened

sound snap of the

with electrocardiogram

the first heart

In

a

delayed

second

sound

and phonocardiogram

no presystolic

; the two components

fuse. is

sound,

similar like and

rumble

of

fashion

the the

aortic

2-0s

recorded

at 25 mm./srcond.

Whrn

is recorded.

distance

either

creased.

LYhen

I,)- inspiration,

remains the

the

same

maneuver

an opposite

train

is

or

is

in-

terminated

of events

takes

place.

TII,'.AMERICAN

,OURNAI.

OF

CARDIOI.OG'.