Download Silent Rheumatic Valvular Heart Disease

Silent
WILLIAM
LIKOFF,
J.
ALBERT
Rheumatic
M.D.,
KASPAR,
Valvular
F.C.C.P.,**
M.D.,tf
KASPARIAN,
L.
SEGAL,
AND
RHEUMATIC
VALVE
DISEASE
seek
valve
findings.”
called
Since
silent.
of all
disease
without
These
lesions
abnormal
this
these
have
implies
the
auscultatory
exists
confirmation
M.D.
the
by means
physician
to
and
of special
MITRAL
Responsible
namic
to
diag-
STENOSIS
Structural
Factors:
in mitral
proper
for
methods.
SILENT
ausbeen
absence
events,
F.C.C.P.,f
NOVACK,
these defects at the bedside
nostic
and murmurs
are audible.
A number
of reports attest to the occurrence
of dynamic
rheumatic
cultatory
knowledge
suspect
can be recognized at the bedside when
characteristic
abnormal
heart
sounds
the
M.D.,
PAUL
Pennsylvania
ficient
IGNIFICANT
Disease*
M.D4
BERNARD
HRATCH
Philadelphia,
S
Heart
stenosis
include
sound,
late
apical
cause the closure of the rigid
mitral
leaflets is delayed
occurring
simultaneously
term,
perhaps
The
by
problem
of
is meaningful
patient
care.
another
silent
and
from
viewpoint
oddity
of
are
not
because
the
incidence
is small
and knowledge
has
tured
slowly.
Considerable
information
however,
based
side observations
and
heart
catheterization,
intracardiac
diac
with
careful
surgery.
reasonable
It
is now
accuracy
for their
importance,
Cardiology
the
*From
Medicine,
Hospital.
United
Section,
Hahnemann
States
Public
Department
icine,
pital.
Section
of
Hahnemann
Cardiology,
Medical
Head of Cardiology,
sor of Medicine,
Hahnemann
and Hospital.
tAssistant
ttAssociate
College
in
and
in
*Associate
College
§ Head,
ogy,
mann
and
Medicine,
Hospital.
of
College
and
Associate
Medical
Hahnemann
Hos-
Hahnemann
Professor
College
of the
valve,
flow
across
for
less
Medical
Medical
of
and
Section
Medicine,
snap
deit
is
of the opening
cusps.
It is not
intensity,
subjects
in
immobile
by the
velocity
the
quality
murmur
and
orifice
and
deformity
patients
stenosis.
of the
murmur
has
with
Explanations
must
considerations
from
respon-
precordium.
phonocardiography
in
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
not
murmurfor
in-
be based
on
or on information
the study of other murmurless
362
of
of blood
factors
to the
and
of mitral
volume
lesions.
Hospital.
is
since
number
of
are relatively
transmission
mitral
derived
Hahne-
opening
diastolic
performed
theoretical
of Cardiol-
same
sound.
flexibility
determined
the
sible
been
College
an
frequency,
Intracardiac
Profes-
Hospital.
Unit,
of
the
movement
a loud
leaflet
stenosis are
Med-
closing
abrupt
cessation
of the mitral
duration
the
has
1).
audibility
Medicine,
Catheterization
Associate
Medical
Professor
of
extensive
systole
then
ochave
opened
fully
to produce
in a large
the leaflets
The
of
time
subsequent
presence
(Fig.
suf-
01.
**Head,
the
limited
heard
whom
Medical
College
and
in part by a grant
from
the
Health
Service
HE 0993 7-
Supported
and
too
movements
inaudi-
by
conduction
by
practical
coaptation
impaired
because
ventricular
before
the leaflets
caused
responsible
If
be-
ventricular
possible
to outline
the anatomic
and
Of
valve.
develops
or by subvalvular
fusion,
a
is not produced.
A short
atrio-
The
the occurlesions
and
sound
calcification
loud
sound
car-
and
or
1).
heart
is severely
upon
factors
favoring
and murmurless
greater
is
bed-
first
pends
mechanisms
bility.
ma-
(Fig.
tricuspid
cusps
effect
curs
data
from
combined
angiocardiography,
phonocardiography
hemodynamic
rence
of silent
the
on
the
the
murmurless
the
clinicians
of the
aware
loud
with
Regrettably,
sufficiently
available,
The
a
murmurless.
defects
murmur
a mild
first
currence
murmur
diastolic
and
findings
a loud
use restricts the term to those rare instances
in which
neither
unusual
heart
sounds
nor
murmurs
are heard.
The more
common
ocwithout
snap
Hemody-
auscultatory
an
of abnormal
sounds
should
be distinguished
opening
and
The
Volume 49.
April 1966
No.
Even
4
SILENT
when
murmur
mitral
may
tude
of
inished
by
volume
of
and
valvular
most
the
also
and
the
factors
causes.
Blood
during
rapid
presence
the
flow
short
atrial
di-
fibrillation
of a thrombus
in
the
some
murmur
subjects,
results
owing
tween
the
from
impaired
to interposition
the apex
and
displacement
with
of
the
the
within
of
the
air
chest
apex
from
the
heart
as when
or
Under
amplitude
of
is presumed
murmur
of the
transmission
the
precordium.
stances,
inaudibility
fluid
bewall
or by
its
these
the
circumas great
heard
at
the
disease.
usually
fatigue,
ness or
advanced
syncope
right
at
state
this
instances
of
The
tatory
findings
in
loud
a
shows
diagram
mitral
first
stenosis
heart
sound
snap (OS),
introducing
a mid
murmur
(DM)
with presystolic
patient
fusion
with
the
of
sound
is
not
The
diastolic
tient
with
murmur
normal
severe
mitral
loud
and
calcification
valve
(B),
an
murmur
silent
first
is
mitral
is absent.
heart
(1),
These
sound
or
the
opening
usually
stenosis
patients
with
an
opening
and late diastolic
accentuation.
In
subvalvular
first
heart
snap
is
In
heard.
(C)
also
no
absent.
the
a
pa-
diastolic
demonstrate
opening
snap.
hy-
explain
why
symptomatic
sinus
and
is enfibrillaand
the
dusky
auscultation
interspace,
and
the
the
pulmonic
of
lower
left
ventricular
the
pansystolic
opening
snap
2).
are
murat
intensified
Occasionally,
sound
area
of mitral
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
the
located
and
gallop
tricuspid
at
findings
border
at the
A
of pulmoheard
regurgitation
a
Split-
is loud.
be
the
2
which
is minimal
murmur
(Fig.
1 or
sound.
sound
These
sternal
inspiration
right
grade
second
2).
tricuspid
third
sound
murmur
heart
with
by deep
localized
soft
may
associated
mur
and
component
(Fig.
lift
valve.
ejection
diastolic
area
usually
second
and
regurgitation
same
the
midsystolic
second
the
output.
right
ventricular
the pulmonary
at
before
the
to
accompanies
pulmonary
a short
of
response
ventricular
of 6 ejection
ting
with
in
which
reveals
closure
of
On
cardiac
tachycardia
left
left
of pulmo-
diminished
often
than
atrial
volume
is small
Palpation
and
loud
the
evidences
and
decreased
terminates
the classic auscul(A). These
in-
assume
are the con-
to
more
vasoconstriction
nary
1:
of
to
pulmonary
is difficult
are not
more
pulse
decrescendo
FIGURE
reamore
mitral
reasonable
reveals
is cold
out
ECG
past
the
symptoms
Curiously,
introduces
I
of
pattern
is
hypertension
countered
tion.
The
I
inpa-
earlier.
severe
cI
many
enjoyed
with
long-standing
pertension,
it
these
subjects
in
in
had
contrasts
Since
it
pulmonary
output.
B-flJJ11IftD--
and
of
arrive
cognizant
devolutionary
stenosis.
that
the
with
weak-
pulmonary
disease,
health,
be
isolated
deterioration
although
heart
leisurely
skin
a
sudden
who,
rheumatic
sonable
abruptly
a persistent
This
tients
the
themselves
recurrent
the manifestations
failure.
They
rather
Examination
Os
a
and
heart
mur-
may
and much
rheumatic
with
present
dyspnea,
after
nary
2
or
stenosis
Patients
defect
marked
precordium.
clude
mitral
encountered
as an isolated
lesion
less
frequently
in
combined
sequences
vibrations
to be
is actually
contact
Silent
Manifestations:
significant
fection.
atrium.’#{176}
In
363
DISEASE
Clinical
valve
ad-
extravenous
impaired
of
and
failure
myocardial,
HEART
murless
is dim-
velocity
from
and
the
ampli-
Congestive
common
be
by
left
flow.
periods
the
vibrations
stemming
are
if
impaired
blood
VALVULAR
is severe
heard
markedly
ditional
astolic
be
intracardiac
shock
may
stenosis
not
the
RHEUMATIC
and
may
confused
stenosis.
be
364
WILLIAM
The
electrocardiogram
ventricular
sinus
rhythm
trophy.
and
not
tion
and,
prevails,
left
survey
reveals
X-ray
atrium
If
indicates
hypertrophy
calcification
seen
can
in
be
large
cusps.
films,
by
the
tory
and
hypertension
image
of mitral
in the
findings.
from
diac
expected
gradient
be
reduced
new
diagnostic
cardiogram,
or
motion
of the
sistance
and
technique,
ultrasonic
mitral
may
the
leflets
indeed
the
apex
30
mitral
sounds
at the
exist
or
mitral
ori-
or is inconsequen-
may
of
the
and
and
second
follows
heart
sound,
mid-diastolic
the
of the
because
ventricular
aortic
orifice
findings
include
heart sound,
pansystolic
intensity
best heard
short
splitting
Hemody-
auscultatory
regurgitation
the
third
varying
be heard
left
the
REGURGITATION
The
mitral
which
Wide
echoof
not
splitting
rumble
is of specific
negate
dynamic
the
car-
reflection
than
a
are not audible
mitral
or aortic
Structural
low-frequency
murmur
of
ventricular
severely
heart
MITRAL
Factors:
wide
ob-
hyperten-
atrial-left
and
of
which
pulmonary
left
namic
particularly
catheterization,
severe
marked
SILENT
Responsible
auscul-
can
studies,
does
and
indev.
A
abnormal
obstruction
either
pos-
be ignored
Confirmation
demonstrates
the
murmurless
less
tial.
of
atrial
cannot
of the
heart
pressure
left
fice
his-
those
that
stenosis
special
the
so clearly
and
absence
tained
combined
of
hypertrophy
tatory
sion,
are
ventricular
sibility
even
implications
examination
pumonary
right
the
regurgitation,
diagnostic
or
of
murmur
of mitral
stenosis
in subjects
with
associated
intensifier.
The
silent
a slope
which
correlates
with
of less than
1 cm.2
When
calcifica-
In
it reveals
mm./sec.
valve
area
left
mitral
catheterization.
stenosis,
hyper-
a
demonstrated
for
normal
atrial
of the
routine
right
if
Diseases
of
the Chest
et al.
LIKOFF,
at
apical
third
heart
sound.
second
heart
sound
only
a portion
of the
output
is ejected
through
and the aortic
valve
closes
early.
The low-frequency
third
heart
sound
is early in diastole
during
the passive
phase
of rapid
ventricular
filling
and
expresses
asneed
IE22
IE
22
ON
PA
iMMiI
11111111
ECG
FIGURE
2:
The
diagram
shows
monary
hypertension.
Tricuspid
ings
of pulmonary
hypertension
short
ejection
mid-systolic
murmur
accentuated
ic murmur
sounds
are
introducing
of tricuspid
also noted,
the
auscultatory
regurgitation
are
a pulmonary
regurgitation
findings
is
also
in
conspicuous,
present.
These
include
(SM).
Pulmonary
valve
regurgitant
murmur
is heard.
Right
sided
a patient
At
with
the
silent
pulmonary
mitral
area
stenosis
and
(PA),
the
introducing
pulfind-
pulmonic
ejection
sound
(E)
a
closure
(P2)
of the second
heart
sound
(2)
is
(DM).
At the tricuspid
area
(TA),
pansystolatrial
(a)
and
ventricular
(3)
diastolic
gallop
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
Volume
49,
April
1966
No.
resistance
trast
4
SILENT
to that
to mitral
sounds
not the
filling.
Therefore,
stenosis,
reflect
the
inflexibility
RHEUMATIC
the
in con-
abnormal
severity
of the
of the second
heart
with left ventricle
and
pulmonary
hypertension
that
are
also
unclear.
The
attributed
to
disappears
heart
sound
apical
the
tation
may
pansystolic
be early
beginning
sound
and
enveloping
when
the
defect
or
is
persist
ventricle
and
path
of
murmur
tude
the regurgitant
is inaudible.
mt.
closure
Intracardiac
that
tract
mitral
vibra-
of the
valve
jet even
However,
vibrations
Diminished
flow secondary
LDM
valve
it is
heart
left
in the
when
the
the ampli-
is considerably
re-
velocity
and volume
of
to congestive
failure
4bM
1
cause
mur
In some subjects,
is related
to
is
particularly
4
true
positioned
in the
pleural
ated
tion
posteriorly
in patients
with
At
the
times,
tract
FLOW)
tion.
in
No
aortography
of
a
patient
diastolic
showed
with
murmur
serious
silent
aortic
was
heard,
yet
cineaortic
regurgitation.
co-existing
mitral
murmur
of
aortic
of
mitral
a silent
practical
murmurless
defect
for
all
pur-
poses.
Subjects
with
isolated
themselves
with
ular
or manifestations
failure
symptoms
erally
irregular
ities on physical
atrial
of rapid,
The
of left
“v”
or
left
electrocardiohyper-
left atrium
is
systole.
Routhe
prominent
catheterization
is
the
diagnosis
waves
may
atrial
pressure
cineventriculography,
be
The
from
defect
the
is brisk
dem-
The
of
materi-
accompanies
history
is
can
be
examination.
and
the
The
left
rather
hypertrophy.
left
atrium
systole
and
On
may
a
be seen
prominent
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
not
suspected,
car-
ventricle
electrocardiogram
biventricular
in
tracings.
however,
regurgitation
the clinical
not
al-
noted
the reflux
of radio-opaque
the left atrium.
pulse
during
loud
heart
ventricular
the
during
heart
establishing
large
gen-
Abnormalinclude
pal-
survey
confirms
and ventricle.
wedge
large
present
ventric-
left
gallop
rhythm,
of the second
fibrillation.
ventricular
the
defect
of
heart
rhythm.
examination
is suggestive
gestive
regurgita-
left
isol-
or
palpable.
in the
OUT-
the
that
latter
otid
(DM)
(LV
cav-
stenosis
completely
obscures
regurgitation
rendering
the
tine
x-ray
left atrium
phonocardiograsn
is
Although
stenosis.5
however,
murmur
ventricle
fluid
mitral
regurgitait is much
more
common
diagnostic.
outflow
into
Manifestations:
When
mitral
mitral
stenosis,
intracardiac
or
or pericardial
silent
or murmurless
has been
reported,
onstrates
al into
diastolic
the
left
air
giant
jet
Left
the
when
murThis
atrium.
the
The
of the
alone.
gitant
though
3:
vibra-
mitral
stethe regur-
Combined
helpful
in
FIGURE
inaudibility
transmission
trophy.
On fluoroscopy,
large
and may pulsate
H
attenuated
ities and when,
with
co-existing
nosis,
the distorted
leaflets
direct
gram
Outflow
demonstrates
the
tions.
and
lL
usually
pable
left
ventricle,
pulmonic
component
.
Phono
365
DISEASE
Clinical
regurgi-
in systole,
the first
severe.
the
third
HEART
or shock
rhythm.
late
with
inflow
above
of these
duced.
blood
the
the
of mitral
indicates
in
murstenosis,
but
aortic
phonocardiography
tions
diastolic
as gallop
murmur
reasons
mitral
failure,
persists
Although
sound
failure
for
relative
with
heart
of regurgitation,
leaflets.
Wide
splitting
may not be heard
mur,
VALVULAR
is
is
than
sugright
fluoroscopy,
to pulsate
left
yen-
366
WILLIAM
tricle
is visualized
in
the
routine
roentgen
The
The
diagnosis
can
be
cineventriculography.
records
the
in excess
The
slope
of
of
160
the
valve
to
and
Hemodynam-
characteristic
auscultatory
of aortic
stenosis
include
a soft or
aortic
component
of the
second
and
a basal
ejection
mid-systolic
murmur
grade
The
2 to 5 in intensity.
second
the
lesion
are
flexible.
sound
is not
significant
failure
or
pulmonary
mitral
nary
component
of
mistaken
for a normal
The
intensity
stenosis
and
congestive
be
the
murmur
shock
stenosis
impairs
tricular
a soft
output.
murmur
However,
persists.
in most
Since
the
second
heart
sound
is
in
a sig-
lefi
present,
silent
and
a
tic
stenosis
may
Murmurless
encountered
as an
be
ated
lesion
or in association
with
mitral
stenosis.11”
When
it is the
aorisol-
dynamic
only de-
fect the clinical
pattern
simulates
that
atherosclerotic
heart
disease
complicated
congestive
failure.
suggested
tricle
by
the
which
The
x-ray
is larger
ed normotensive
ease and by the
correct
size
than
of
by
diagnosis
of the
is
left
ven-
in decompensat-
atherosclerotic
demonstration
tatory
finding
tation
is an
early
the
heart
disof calcified
in subjects
rheumatic
dient
across
under
the
responsible
the
aortic
valve
pathophysiologic
for the murmurless
cineventriculography,
dysfunction
of
however,
one
or
more
is not
produced
circumstances
lesion.
Left
does
of the
reveal
leaflets.
be heard
even
mitral
additional
disease
This
and
including
regurgitation
oc-
signifmi-
and
tor-
stenosis.
As yet,
view that
ble
for
there
reduced
the
is no confirmation
output
is solely
attenuated
(Fig.
3).
have
been
output
Indeed,
ing
valve
gest
that
arities
valve
the
recorded
and
also
disease.’
of the
motion
murmur.
be
is high
anatomic
and the
intensity
below
murmurs,
pa-
vibrations
variations
severity
in
of co-exist-
observations
perhaps
defect,
physical
jet
and
and
Alterations
in output
frequency
wide
These
factors,
frequency
mitted.
change
in
regurgitation
the
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
of
mateof the
however,
murmur
is poorly
trans-
of a profound
sufficient
to re-
a critical
on the
peculi-
contribute
audibility
at best
short
may
be
sug-
the
the details
characteris-
Aortic
regurgitation,
exception
because
an
recorded
diminished
with
in the
other
of the
responsi-
vibrations
by intracardiac
phonocardiography
tients
with
murmurless
aortic
duce
murmur
or along
the
clearly
docu-
is marked.’
with
valve
stenosis,
ausculregurgi-
max’ not
precordium
regurgitation
may
gra-
area
been
the murmur
from
the
helpful
pressure
Hemody-
diastolic
aortic
It has
tics of the regurgitant
rially
to the intensity
a meaningful
and
blowing
at the
border.
mented
that
or recorded
tral
REGURGITATION
The
fundamental
in rheumatic
aortic
aortic
leaflets
through
routine
roentgen
examination
or with
the
aid of the
image
intensifier.
Left heart
catheterization
is not
because
ventricular
hvperbe concluded
by
Structural
Factors:
tic
rarely
Manifestations:
AORTIC
namic
curs
icant
murmurless.
Clinical
can
or
and
demonstrating
calcification
of the
aortic
leaflets
by image
intensification
and
immobility
of the leaflets
by left cineventricu-
when
ven-
instances
abnormal
is uniformly
is never
reveals
a palaortic
component
left
film
confirm
The diagnosis
heard
best
left sternal
aortic
when
mitral
lesion
pectoris
symptomatol-
x-ray
trophy.
SILENT
cause
pulmo-
of
nificant
significant
angina
in the
ste-
patients
sound
is diminished
electrocardiogram
Responsible
reduced
and
when
is included
Physical
examination
left ventricle.
The
leaflets
stenosis
the loud
considerably
failure,
stenosis
in
of the second
heart
inaudible.
Both
the
congestive
the second
sound
aortic
sound.
of
may
aortic
suggested
when
the
when
co-existing
hypertension,
murmurless
lography.
only
is normal
Occasionally,
mitral
ogy.
pable
be
of
frequently
or syncope
STENOSIS
Structural
The
is
with
left
echocardiogram
mitral
AORTIC
Responsible
ic Factors:
by
mm./sec.
SILENT
findings
absent
sound
confirmed
of
Chest
the
presence
nosis
survey.
Diseases
et a!.
LIKOFF,
other
level.
hand,
Loware
Volume
49,
April
1966
No.
readily
4
transmitted
dible
even
severely
and
until
RHEUMATIC
may
cardiac
persist
output
which
Manifestations:
cannot
as auhas
The
pressure
pulse
is palpable.
if the
with
brisk
aortography
reveals
left
to the mitral
pulse
pressure
systolic
suggest
murmur
at the base
the correct
diagnosis.
of the
In
regurgitation
and a loud
be
be
presence
of
large
Both
they
However,
radiologic
are
tributed
to obstruction
The
nent
The
also
exceptional
of the
left
ventricle
aortic
patible
root dilatation
with
isolated
possibility
are
present
not
in aortic
increase
associated
in
with
are sufficiently
aortic
stenosis
of
aortic
can
of
TRICUSPID
tensity
incomto sug-
regurgitation.
and
These
space
just
and
over
sound
murmurless
by a promipulse.
right
a
of
fluoroscopy
routine
the
and
roentgen
is confirmed
diastolic
exby
pressure
REGURGITATION
Structural
the
mur.
valve.
the tricuspid orifice.
across
stenosis.
marked
at-
mitral
venous
indicate
on
diagnosis
ic Factors:
The
findings include
sound,
pansystolic
size
aortic
erroneously
jugular
may
the
obin-
of tricuspid
Enlargement
on
SILENT
When
of the
be seen
The
Responsible
helpful
and
hypertrophy.
atrium
instances
are
merely
stenosis
which
of silent
and
is suggested
demonstration
associated
of
the
and murto be com-
findings
generally
“a” wave
in the
electrocardiogram
gradient
electrocar-
when
over
lesion.
the
presence
stenosis
tricuspid
right
indications
enlargement
are
stenosis
atrial
The
even
in many
is a co-existent
aortic
necessarily
inindi-
Silent
appear
findings
of mitral
is present,
the
pressure.
most
an
stenosis
in the in-
recorded
However,
stenosis
the
and
ventricular
clinically.
amination.
not
or
stenosis
the
auscultatory
scured
by those
is conspicuous
are
left
mon
the
pulse
heard
Manifestations:
the
These
right
tricuspid
of
a wide
be
Clinical
murless
and
with
the
of
phonocardiography
not
mitral
regurgita-
is
precordium.
with
suggesting
snap
is inflex-
cause
ventricle
have
aortic
flow
of the
tract
pulse
in
blood
valve
flow
sound
valuable
sternum.
with
in-
opening
the
of tricuspid
itself and
carotid
murmurless
the
when
the murmur
at the valve
of
with
the
and mitral
to
at the fifth
to the ensi-
cates
that
is loudest
closure
tion.
since
a diastol-
murmur.
loud
are
of
diographic
appear
find-
and
pathophysiologic
a brisk
a
valve
possibility
common
variably
of the heart
In addition,
or in combination
regurgitation,
the
sus-
alone.
ejection
dilated.
stenosis,
develop
Intracardiac
inand
unusually
aorta
who
alone
aortic
audible
be
alone.
patients
stenosis
can
may
these
findings
are
inconsistent
diagnosis
of the mitral
stenosis
regurgitation
Diminished
in
erroneously
mitral
ible.
mitral
stenosis
Under
these
of left ven-
attributed
A wide
root
in
not
it can
involvement
the
snap
or to the right
may
become
may
of radio-opaque
tricular
and
As
in
suggests
is experienced
may
process
murmur
conaorthe left
the x-ray
enlargement
pecting
the diagnosis
when
and regurgitation
are present.
circumstances,
the indications
ventricle
or
ventricle.
difficulty
left
opening
spiration.
to
matter
reflux
the
mitral
carotid
alone
electrocardiogram
hypertrophy,
ventricular
the
co-exist-
enough
murmurless
when
The
left ventricular
dicates
left
Greater
an
Hemodynam-
auscultatory
of the
louder
to the
are
reasons
diagnosis
of
particularly
into
include
major
form
The
attributed
a wide
material
diagnosis
The
be
pulse
concluded
Factors:
ings
STENOSIS
and
best
patients
of a
ventricle
TRICUSPID
Structural
ic murmur
which
are heard
left interspace
and transmitted
lesions.
In
the
presence
or
SILENT
Responsible
been
367
DISEASE
aortic
regurgitation
usually
by
clinical
manifestations
ing valve
stenosis,
combination
template
the
tic regurgitation,
HEART
ic
murmurless
suggested
gest
VALVULAR
impaired.
Clinical
of
is
SILENT
at
are
and
Hemodynam-
fundamental
auscultatory
low-pitched
third heart
murmur
of varying in-
times
heard
a short
at
diastolic
mur-
fourth
inter-
the
to the left or right
of the sternum
the ensiform
process.
The
third
is initiated by
increased
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
right yen-
368
WILLIAM
tricular
filling
murmur
flux
and
resistance.
is formed
when
is responsible
nosis.
These
audible
flow,
events
when
volume
atrial
is markedly
in-
output,
velocity
and
of intracar-
attention
In
most
and
instances
auscultatorv
the
murmurless
by
clinical
at
the
investigation.
to
the
pre-
RESU
Intracardiac
phonocardiography
the murmur
is formed
be heard.
in the
flow
tract
path
at the tricuspid ori-
of the
of the
Clinical
reflux
right
ma
in the
Silent
encountered
be
severe
mitral stenosis or
duces
marked
in-
tricuspid
when
regurgitation
pulmonary
pro-
themselves
with
of intractable
ventricular
failure.
Physical
examinareveals
right
ventricular
enlargement,
the auscultatory
findings
of mitral
disease
and pulmonary
hypertension,
tomegaly
and peripheral
edema.
The
of
indication
with
the
lar
prominent
The
the
and
presence
atrium
wave
in the
systolic
of
right
atrium
The
rou-
gen views
of
be confirmed
can
reflux
by
right
plied
silent
and
murmurless
to hemodynamically
matic
valve
panied
by
disease
audible
able abnormal
Lesions
cannot
murless
unless
performed
by
are
significant
which
and
is
not
graphically
accomrecord-
observers
with
casos
estas
identificadas
Ia
clinica
ser
confir-
en
exploraci#{243}n
ordinarios.
diagn#{243}stico
procedimiento
lesiones
manifesta-
puede
de
Una
investigaciOn
mas
dos.
males,
de silencieux
des
aques
par
conime
ait
une
niques
Dans
ou
non
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cardi-
graphiquement
enre-
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sans
#{233}tre clas#{233}es
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tr#{233}s meticuleuse
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sugg#{233}r#{233}e
par
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tech-
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l’auscultation.
heaucoup
affection
et
et
tie
#{233}t#{233}
par des
attention
de
brs,its
audihies
silencieuses
l’examen
soot
rhumatis-
significatives,
des
lesions
Les
souffle
valvulaires
h#{233}modynamiquement
anormaux
avec
et sans
affections
accompagrsecs
silcncieuse
des
d’examen
diagnostic
Ia
presence
ott
sans
manifestations
#{233}tre
identifi#{233}es
m#{233}thodes
aprheu-
heart
sounds
and murmurs.
be classified
as silent or murthe examination
has been
competent
los
art
lit
peut
d’une
souffle
est
cliniques
du
nialade
hahituelles.
qui
ou
Une
#{234}tre confirm#{233}
m#{233}thodes d’investigations
SUMMARY
terms
el
por
meticulosa
determinan
ser
sospechadas
pect#{233}, le
The
susby
of
RESUM1
de
cineventriculography.
de
m#{233}todos de
gistables.
may
right
in the
diagnosis
the
los
atenciOn
murmullos
pueden
que
o por
a
diagroent-
heart.
The
demonstrating
ciones
con
parte
sin
pliques
hypertrophy.
Once
confirmed
methods
auscultatorias.
mayor
y
rests
tine roentgen
views of the heart.
The
nosis can be confirmed
in the routine
the
by
Ia
termes
suggest
prominent
En
silentes
Les
may
atrial
t#{233}cnicas
refina
jugu-
be
ordi-
MEN
competentes
las
mado
pulsa-
of the right
fluoroscopy.
is unusually
a
%‘ez
hepatic
electrocardiogram
Systolic
pulsations
be discernible
by
servadores
valve
hepabasic
insufficiency
“v”
pulse
venous
tions.
tricuspid
can
Los t#{233}rminos “silente”
y “sin
murmullo”
se
aplican
a
afecciones
valvulares
de
importancia
hemodin#{225}mica
que no se acompa#{241}an
de ruidos
cardiacos
anormales
o de murmullos
audibles
y
registables.
Ninguna
lesion,
sin embargo,
puede
ser
clasificada
como
silente
a
menos
que
el
ex#{225}men
de corazOn
hava
sido efectuado
pot ob-
hypertension.
Subjects
generally
present
the
clinical
manifestations
right
tion
and
ventricle.
Manifestations:
regurgitation
it cannot
even when
It is recorded
fice
reveals
silent
or through
atrium
cordium.
of
is suggested
which
bedside
nary
methods
of examination.
pected
the diagnosis
can be
definite
and more
sophisticated
transmission
tech-
presence
disease
valve
manifestations
identified
Inaudi-
to
bility
may
also result
when
the regurgitant
jet is directed
posteriorly
into the large
right
impairing
diminished.
the Chest
niques.
ste-
become
cardiac
and
re-
tricuspid
Diseases of
at.
meticulous
diastolic
a large
relative
auscultatory
the
diac
for
mainly
hence
The
et
LIKOFF,
l’aide
fois
sus-
par
des
absolues.
ZUSAMMENFASSUNG
Die
Bezeichnungen
stumm
werden
auf h#{228}modynamisch
tische Klappenerkrankungen
verkn#{252}pft sind mit hOrberen
zeichenbaren
chen.
oder
nicht
abnormen
und
gerauschlos
signifikante
rheumaangewandt,
die nicht
und graphisch
auf-
Herzt#{246}nen
und
Ger#{228}us-
Die Veranderungen
k#{246}nnennicht als stumm
garauschlos
eingeordnet
werden,
so
lange
die Untersuchung
durch
kompetente
Beo-
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017
49,
1966
Volume
April
No.
4
bachter
und
keit auf die
f#{252}hrt
worden
SILENT
mit peinlich
auskultatorisehe
ist.
RHEUMATIC
VALVULAR
genauer
AufmerksamTechnik
zuruckge-
5
vermuten
die man
durch
klinische
am Krankenbett
Untersuchungsmethoden
durch
best#{228}tigen
durch definitive tmd
sucheinmal
nose
der
Verdacht,
die
B.
sociation
sive
J.
Diag-
9
ungsmethoden.
nosis
1952.
2
3
AND
Thrombi
in
263:423,
Stenosis,”
Cardiologia,
Diagnostic
Med.
Clin.
Clin.
AND
GEOKAS,
America,
AND
S.:
SAMUELSSON,
Acta.
Med.
aspergilloma
served.
ties
out
In
one,
fatal
followed
other,
the
the
x-ray
spontaneous
of 35 cases
of
masses
examination
showed
of
monary
asperglilosis
were
a
nary
clinical
fistula
hemoptysis
cavity.
The
course
of
pulphenomenon
of un-
rare
death.
Early
patients
by
eventual
diagnosis
massive
by
surgical
are
to
seven
the
with
cases
of
this
TO
angiography
entity.
A.:
“As-
with
New
MasEngi.
ZIJCKERBROD,
Thrombi,”
“Rheumatic
Heart
of Left
J.,
Disease
Am.
Auricle,”
W.
ABELMAN
Manifestations
and
Review
of
One-Hundred
Arch.
mt. Med.,
94:911,
AND
L. B.:
ELLIS,
please
write:
Philadelphia.
Dr.
with CalClinical
M.,
-Clinical
Disease:
Cases,”
VASQUES.
“Aortic
Stenosis
Course
of
the
Proved
1954.
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230
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ASPERGILLOMA
known
origin.
Attention
the
early
stage
of their
pearances
of aspergilioma
it can
imitate
of
and
and
prompt
patients
made
prior
reported
P.,
KRAKOWEA,
H.:
is called
to the
fact
that
development,
the
x-ray
is not
a characteristic
pulmonary
in
apone
tuberculosis.
J..
GRYMINSKI,
Spontaneous
Grsizlica,
33:431,
WEG,
loma,’’
of
report
of
Nine
cases
with
three
GARRET.
AND
monary
H.
of
E.,
Fistsila.”
Pulmonary
I. AND HAL.
Aspergil.
1965.
two
cases
of
fistulas
the
pertinent
this
entity
patients
DEBAKEY,
of
FISTULA
of
aortopulmonary
summary
KONONOWICZ,
Necrosis
‘
AORTOPULMONARY
A
bouts
hemorrhage
therapy
are
required
if additional
to
be
salvaged.
The
diagnosis
was
death
in only
two
of the
previously
AND
H.
PULMONARY
aortopulmo-
repeated
Atrium,”
MILAN,
and
the
M.
and
SECONDARY
course
of
is characterized
with
caviIn
the
HEMOPTYSIS
The
the
ob-
expectorated
of
within
is
of
aspergilloma.
closure
aspergiliomas
were
Infection
of
OF
Am.
Stenosis
Thrombosis
For
reprints,
Broad
Street,
pulmonary
aspergillosis
purulent
necrosis
aspergiflous
necrosis
of
of
A. J.:
KASPAR,
Auricular
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42:667,
S.:
BEROERON,
Mi-
AND
1951.
H. A.: “Aortic
Stenosis
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Distinct
JAMA,
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Entity,”
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CHRISTIAN,
12
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Murmurs,”
KROEKER,
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Am.
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SWANPOEL.,
In den meisten
Fallen
lal3t sich das Vorliegen
stummer
oder ger#{228}uschloser Klappenerkrankungen
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a
presented.
now
by
“Hensoptysis
Thor.
treatment
operation
literature
salvaged
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