Download GRAPHIC TECHNIQUES IN CARDIOLOGY and

GRAPHIC
TECHNIQUES
and Exaggerated
Closure
of Atrial
Persistent
Successful
Kuang-Hung
Tye,
Alberto
Benchimol,
T
he
defect,
port
of
pulmonary
herein
whom
the
the
successful
ejection
edema
second
( P2 )
ejection
murmur
The
ejection
spiration.
tricular
nary
ankles.
heart
heart
sound
(S2
second
heart
followed
at
the
click
1A
.
following
loud
of
and
a systolic
systolic
ejec-
tricuspid
areas.
during
demonstrated
prominence
demcompo-
and
Cardiac
to our
dyspnea
pulmonic
3/6
right
of the
catheterization
inyen-
pulmowas
#{176}Fromthe Institute
for Cardiovascular
Diseases,
Good Samaritan
Hospital,
Phoenix,
Ariz.
Supported
in part by the E. Nichols
and Kim
Sigsworth
Memorial
Funds and the Institute
for Cardiovascular
Diseases, Inc.
Reprint
requests:
Dr. Benchimol,
Good
Samaritan
Hospital,
Phoenix
FIGunz
1. A (left),
Chest x-ray film prior to repair
pulmonary
arteries,
with abrupt
tapering
Chest
x-ray film nine years after surgical
artery
is markedly
dilated
(Jan 5, 1978).
of central
B ( right),
nary
CHEST, 74: 4, OCTOBER, 1978
sure
was
of an atnial
septal
defect
of 2.5 to 1; the pulmonary
88/30
mm
any
repeat
arterial
evidence
shunt.
the
of an
type
interval
second
heart
crease
of
defect
was
mentation
period
between
of the
been
The
intensity
the
of
aortic
and
component
of the
and
in-
a marked
ejection
click,
augwhich
is
2).
delineated
the
through-
P2, a progressive
P2,
pulmonary
of
artery
Serial
phonocardiograms
have
indicated
a shortening
auscultatory
associated
well
resolution
roentgenographic
.
( A2 )
( Fig
Characteristic
graphic
findings
have
)
intensity
in timing
had
pulmonary
lB
indicated
a
Hg, with-
mm
complete
has
enlarged
sound
the
Despite
patient
( Fig
the years
a nine-year
of the
earlier
A secundum
cardiac
catheterization
pressure
of 50/25
residual
of symptoms,
out
over
Hg.
with
a left-toarterial
pres-
repaired.
In 1973,
pulmonary
out
splitting
in intensity
film
)
in
fixed
a grade
diminished
and
re-
examination
sound,
pulmonic
x-ray
enlargement
( Fig
by
We
defect.
sound,
diagnostic
right
shunt
successfully
a patient
initially
referred
of exertional
), a
pul-
secondary
louder
septal
Physical
first
A chest
artery
from
a loud
click
tion
dilation.’3
became
atnial
primary
or
arterial
woman
was
with complaints
of the
defect,
recordings
click
as-
stenosis,
idiopathic
of an atrial
of the
onstrated
nent
graphic
repair
A 61-year-old
clinic
in 1969
the
septal
and
Click after
M.D.,
F.C.C.P.;
Silvestre,
M.D.
is traditionally
valvular
ventricular
CARDIOLOGY
Pulmonary
Ejection
Septal Defect*
B. Desser,
and Agenor
sound
pulmonary
hypertension,
varieties
Kenneth
F.C.C.P.;
ejection
with
monary
and
M.D.;
M.D.,
pulmonary
sociated
septal
IN
with
and
atrial
during
first
heart
the
sound
phonocardioseptal
defect
past
may
50 years.
be
ac-
centuated
due
to a loud
component
of tricuspid
closure.”7
In uncomplicated
cases
the second
heart
sound
is split at an A2-P2 interval
ranging
from 0.04
to 0.08 second
and
“fixed,”
with
-
respiratory
variation
.
of atrial septal defect.
There is prominence
of right pulmonary
artery
(Jan 15, 1969).
closure of atrial septal defect.
Right pulmo-
PERSISTENT AND EXAGGERATED PULMONARY EJECTION CLICK
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445
2. A ( left),
Simultaneously
recorded
( TA ) pulmonic
area ( PA ) and aortic
phonocardiograms
of mitral
area
(MA),
tricuspid
area (AA) , external
jugular
venous pulse tracing
(VT),
and lead 2 (LII)
of electrocardiogram
prior to closure of atrial septal defect. Loud first
heart sound ( 1 ) is followed
by pulmonic
ejection
click. Second heart sound is widely
split. There
is prominent
jugular
venous v wave. B ( right),
Phonocardiograms
obtained
nine
years
after
closure
of atrial
septal defect
show prominent
pulmonary
ejection
click
(C).
Note that first
heart sound ( 1 ), click, and A9-P2 interval
of second heart sound (2) have shortened
and that
P2 is markedly
increased
in amplitude.
CT, External
carotid
pulse tracing.
FIGURE
,
area
usually
less
than
0.02
second.4’7-9
diognaphic
characteristics
right
ventricular
third
(2)
systolic
,
ejection
murmurs
pulmonic
areas;4’7’8
murs
with
presystolic
(3 )
snaps
increased
representing
Other
phonocar-
at the
tricuspid
flow
(5
and
secondary
tenial
pressure
to
)
pulmonary
elevation
or
a
Classically,
P2 increases
terval
shortens,7
and
louder
as pulmonary
in
the
the
hypertension
ejection
pulmonary
ar-
artery.7’8
pulmonary
intensity,
ejection
tn-
stenosis;1#{176}
valvular
pulmonary
systolic
of the
dilated
muropening
across
valve,4’7’8
or concomitant
mitral
(4) murmurs
of tricuspid
and pulmonary
incompetence
in the presence
of marked
clicks
and
early
or mid-diastolic
accentuation
and
cuspid
hypertension;
REFERENCES
include
the following:
(1)
and
fourth
heart
sounds;7’8
the
click
A2-P2 inbecomes
intervenes.
Of interest
in the case described
herein
was the
occurrence
of both
auscultatory
and phonocardiographic
concomitants
of such
presumed
pulmonary
hypertension
sures
over
diminished
a period
of time
when
and
the
patient
became
that
echophonocardiographic
ejection
clicks,
whatever
moment
of a complete
symptoms.
studies
have
Combined
indicated
their
occur
cause,
at
the
opening
of the semilunar
such
clicks
in relation
to
pulmonary
artery
remains
valve.’12
increasing
a fruitful
such
presfree
of
The genesis
of
dilation
of the
area
for
future
research,
ACKNOWLEDGMENT:
We thank
Carole Crevier,
Ms. Sydney
Peebles,
for technical
assistance.
448
Ms. Kathy Tustison,
Ms.
and Ms. Betty Kjellberg
1 Leatham
dilatation
A, Vogelpoel
L:
of the pulmonary
The early systolic
artery.
Br Heart
J
sound
in
16:21-33,
1954
2 Karnegis
JN, Wang
Y: The phonocardiogram
in idiopathic dilatation
of the pulmonary
artery.
Am J Cardfol
14:75-78,
1964
3 Deshmukh
M, Gavenc
5, Bentivoglio
L, et al: Idiopathic
dilatation
of the pulmonary
artery.
Circulation
21:710716, 1960
4 Leatham
A, Gray I: Auscultatory
and phonocardiographic
signs of atrial
septal
defect.
Br Heart
J 18:193-208,
1956
5 Lopez JF, Linn H, Shaffer AB: The apical first heart
sound as an aid in the diagnosis
of atrial
septal defect.
Circulation
26: 1296-1301,
1962
6 Sanchez J, Rodriguez-Torres
R, Lin JS, et al: Diagnostic
value of the first heart sound in children
with atrial septal
defect. Am Heart J 78:467-475,
1969
7 Benchimol
A : Non-invasive
Diagnostic
Techniques
in
Cardiology.
Baltimore,
Williams
and Wilkins
Co, 1977, pp
284-293
8 Dimond
EG, Benchimol
A: Phonocardiography
in atrial
septal
defect:
Correlation
between
hemodynamics
and
phonocardiographic
findings.
Am Heart
J 58:343-356,
1959
9 Myler
RK, Sanders
CA: Normal
splitting
of the second
heart sound in atrial
septal
defect.
Am J Cardiol
19:874879, 1967
10 Steinbrunn
W, Cohn KB, SeIzer A: Atrial
septal defect
associated
with mitral
stenosis:
The Lutembacher
syndrome revisited.
Am J Med 48:295-302,
1970
11 Waider
W, Craige
E : First heart
sound
and ejection
sounds. Am J Cardiol
35:346-356,
1975
12 Mills P, Brodie
B, McLaurin
L, et a]: Echocardiographic
and hernodynamic
relationships
of ejection
sounds. Circulation 56:430-436,
1977
TYE ET AL
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CHEST, 74: 4, OCTOBER, 1978