W. Proctor Harvey

Systolic clicks and the late systolic murmur: Intracardiac phonocardiographic evidence of their mitral valve origin☆

Abstract The use of intracardiac phonocardiography has been employed as a method of documenting the origin of systolic clicks associated with an isolated late systolic murmur in a patient with hemodynamic evidence of mitral incompetence. Registration of both of these acoustical events within the left atrial chamber has not been hitherto described. Response of the clicks and murmur to the infusion of pressor amine and to the inhalation of amyl nitrite adds further weight to the concept of their origin at the mitral orifice. These observations confirm and extend previous information relating the late systolic murmur to organic mitral incompetence even if the murmur is accompanied by systolic clicks.

Auscultatory and phonocardiographic manifestations of pure mitral regurgitation

Summary Auscultatory and phonocardiographic studies are reported in 33 patients in whom pure, organic mitral regurgitation was believed to be the sole hemodynamic fault. Comments were made regarding the nature of the systolic murmur, second heart sound, third heart sound, middiastolic murmur, and opening snap. The study included a discussion of the effects of pressor amine infusion and amyl nitrite inhalation. Comment was made on the additional acoustic events that might occur when mitral incompetence is associated with pulmonary hypertension.

Clinical Recognition of Tricuspid Stenosis

Clinical criteria for the recognition of tricuspid stenosis were studied in 13 cases, all personally observed by the authors. The results suggest that application of these criteria not only allows a confident diagnosis of tricuspid stenosis in a substantial majority of cases, but also allows the lesion to be recognized relatively early in its natural history.

Diagnosis and treatment of primary myocardial disease.

PRIMARY MYOCARDIAL DISEASE represents a pathologic process predominantly involving the heart muscle. It is a distinct type of heart disease from arteriosclerotic, syphilitic, hypertensive, rheumatic, cor pulmonale, and congenital heart disease. Various terms other than primary myocardial disease have been used to denote this condition, some of which, are myocardiopathy, cardiomyopathy, cardiopathy, myocardosis, myocarditis, diffuse myocardial disease, idiopathic cardiomegaly, idiopathic cardiac hypertrophy, and familial cardiomyopathy or cardiomegaly. Differences in terminology and classification have been a major contributing factor to present and past confusion. Some authors confine the term to include only those patients with unknown etiology (idiopathic group); others include in addition, many known conditions affecting the myocardium (table 1). We prefer a broader classification (as does Mattingly) that differs from some of the other contributors in this symposium and includes both known or specific causes and unknown or idiopathic. We have divided our patients into two groups-one a specific etiology and the other idiopathic. It has been our clinical impression that regardless of whether the specific causes of primary myocardial disease were known or unknown, the clinical features and course were often quite similar. Analysis of a large number of our patients has supported this clinical impression. We also believe and predict that with earlier

Bacterial endocarditis related to cleaning and filling of teeth: With particular reference to the inadequacy of present day knowledge and practice of antibiotic prophylaxis for all dental procedures

Abstract Data are presented on five patients with bacterial endocarditis following dental procedures involving cleaning and/or filling of teeth (no extractions). Three patients subsequently died from complications. Str. viridans was cultured in four cases. Histories from 258 patients with rheumatic or congenital heart lesions revealed that only a minority was informed concerning the importance of prophylaxis prior to extractions, and in still fewer instances was there knowledge of its importance in relation to the cleaning and/or filling of teeth. The importance of the role of close cooperation of the physician, patient and dentist is stressed as a necessity in prevention of this aspect of heart disease.

The clinical diagnosis of acute severe mitral insufficiency

Abstract The clinical and hemodynamic data of 8 patients with acute severe mitral insufficiency are presented. The natural history, physical signs, electrocardiogram, X-ray films and findings at cardiac catheterization present a characteristic picture which is distinct from the chronic form of the disease. The murmur is loud, apical and holosystolic with a late systolic decrease. It frequently radiates towards the base, mimicking aortic stenosis, and it is accompanied by an atrial sound and a third heart sound. Physical findings of pulmonary hypertension are present. Left atrial enlargement and atrial fibrillation are conspicuous by their absence. The basic pathology lies in the suspensory apparatus of the valve rather than in the leaflets. Four patients had ruptured chordae tendineae. If careful attention is paid to all of the clinical features, an accurate diagnosis can usually be made on clinical grounds alone.

The auscultatory findings in primary myocardial disease.

Abstract The auscultatory abnormalities in primary myocardial disease have been reviewed. These abnormalities occur as manifestations of conduction defects, ectopic rhythms, myocardial failure, and associated pericarditis.

The electrocardiogram of myocardopathy

Abstract Myocardopathies rank among the most common cardiac disorders. Although causing a diversity of findings, myocardial disease may be sufficiently characteristic to justify clinical diagnosis. Prolonged observation of living patients and careful correlations of ECG and autopsy findings has improved the physicians ability to assess this group of diseases. Mild myocardial involvement causes T wave abnormalities; severe myocardial involvement causes bundle branch block and hypertrophy patterns. Block of the left bundle branch system is the most common abnormality observed in autopsied cases of chronic myocardopathy and generally represents wide-spread pathology. Both acute and chronic myocardial disease may simulate myocardial infarction. Any arrhythmia may occur at any stage of the disease; ventricular irritability is frequent and relates to the sudden deaths which often terminate myocardopathy, sometimes when pathologic findings are only moderately advanced. Most patients maintain sinus rhythm; only 10 per cent have atrial fibrillation or flutter, usually paroxysmal. The PR interval frequently lengthens, yet complete AV block is rare. QT prolongation occurs in most cases. Certain secondary myocardopathies present distinctive patterns. Hypertrophic subaortic stenosis often causes deep Q deflections in the left precordial leads. Cardiac amyloidosis commonly causes low voltage and may lead to deep, broad Q deflections resembling myocardial infarction. Muscular dystrophy may give rise to tall right precordial R deflections; glycogen storage disease often shortens the PR interval. Chagas disease commonly causes right bundle branch block with left axis deviation. The evolution of electrocardiographic changes has important prognostic significance. Serial electrocardiography is essential to the proper management of myocardial disease.

Auscultatory findings in diseases of the pericardium

Abstract A friction rub characteristic of pericarditis is composed of several components, the typical friction rub having two or three. The first part (provided the rhythm is normal sinus) is related to atrial systole, resulting in a friction component in presystole. The second component is related to ventricular systole, producing a systolic friction rub. The third component generally occurs in the early to middle phase of ventricular diastole, apparently coincident with the time of rapid filling. Sometimes only two components are heard which may be related to atrial systole and ventricular systole. If the rhythm is irregular with atrial fibrillation (thereby having no atrial component), a friction rub having two parts is produced in ventricular systole and diastole. As a practical rule, one should hesitate to make a diagnosis of acute pericarditis after hearing only one friction component in systole, although occasionally it may represent an early finding of pericarditis with the diastolic component appearing subsequently. The auscultatory results in pericardial effusion and constrictive pericarditis are discussed.

Some Pertinent Physical Findings in the Clinical Evaluation of Acute Myocardial Infarction

THE CLASSICAL HISTORY and physical findings of the clinical evaluation of acute myocardial infarction are well known and are discussed in the textbooks of medicine and cardiology as well as in the medical literature. It therefore seems appropriate to focus on some of the newer or poorly recognized clinical features of acute myocardial infarction that have recently assumed greater importance or are now deserving of special emphasis.