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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 souffles cardi- graphiquement enre- peuvent sans #{233}tre clas#{233}es a souffle observateurs moms que comp#{233}tents. tr#{233}s meticuleuse d’exemples, valvulaire sugg#{233}r#{233}e par peuvent ap- tech- aux 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. Likoff, 230 North 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 1951. 42:667, S.: BEROERON, Mi- AND 1951. H. A.: “Aortic Stenosis of the Cusps-A Distinct JAMA, 97:158, 1931. Entity,” 171:723, Car- J., 41:144, CHRISTIAN, 12 NECROSIS necrosis A. cification 1960. “Silent Scand., SPONTANEOUS cases 12:7, H.: J. Regurgitation,” B. L. Left Massive Heart “Silent 1961. KASPARIAN, Am. Mitral the Left 1960. STOLZER, J., Heart with M. C.: “Unin Mitral Stenosis,” 47:279, 1963. Problems Stenosis.” Bull., AND NIERENBERG, “Obstructing YUSKIS, Ste- 21:599, J. M.: POUGET, Lahey North E. MALERS, tral 1962. AND E. J. usual Two “Mitral 11 J. E. KROEKER, G., MILLER, 10 D. E.: LOVE, Murmurs,” KROEKER, Mitral 4 A. S. without LEVINE, AND “Silent” Med., Am. 1 of M.: REFERENCES P. 1964. SURAWICZ, Unter- verfeinerte so l#{228}l3t sich J., 61:723, Heart 7 SEGAL, B. L., LIKOFF, W. “Silent Rheumatic Aortic J. Cardiol., 14:628, 1964. 8 Besteht kann. M., Mitral NELLEN, “Silent Phonocardiography,” 13:188, diol., BECK, NOVACK, “Intracardiac die #{252}blichen ermittein AND Am. B. L., SEGAL, L., W.: VOGELPOEL. A. Incompetence,” Manifestationen, oder V., SCHRIRE, 6 369 DISEASE SWANPOEL., In den meisten Fallen lal3t sich das Vorliegen stummer oder ger#{228}uschloser Klappenerkrankungen HEART 5.: J. have R. K., a*d and is LEWIS, been documented operation. J. M., HOWELL, J. F. Secondary to Aortopul- Cardievasc. 1965. Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21431/ on 05/11/2017 a presented. now by “Hensoptysis Thor. treatment operation literature salvaged RICKS, M. successful by Ssrg.. 49:588,