Apical diastolic and presystolic murmurs of proved functional nature

      This paper is only available as a PDF. To read, Please Download here.


      We have collected a series of thirty-two clinical cases in which a diastolic or presystolic murmur simulating that of mitral stenosis was recorded in the phonocardiogram. The functional nature of the murmur was proved in nine by autopsy, in ten by right heart catheterization (pulmonic stenosis or septal defect), and in thirteen by left heart catheterization, which revealed the absence of a mitral gradient.
      A clinical error was made in most cases, except those in which an entirely different clinical picture was present (congenital heart disease, recent myocardial infarct).
      The phonocardiogram was correctly interpreted in most cases. However, in five cases the tracing was interpreted as being consistent with mitral stenosis. In two of them a “dynamically insignificant” mitral stenosis was suspected, although not proved. In the other three, no stenosis whatsoever was finally admitted.
      A case in which the murmur was probably due to acute rheumatic carditis is discussed in detail and repeated tracings are presented.
      The various causes which can lead to a clinical error are listed and it is shown that, in many of these cases, a phonocardiogram helps to rule out mitral stenosis.
      It is further shown that in a few exceptions even the phonocardiogram can be misinterpreted. Left heart catheterization often reveals the absence of a mitral block thus reducing the doubtful cases (dynamically insignificant lesion) to a minority.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Flint A.
        On cardiac murmurs.
        Am. J. M. Sc. 1862; 44: 29
        • White P.D.
        A note on the differentiation of the diastolic murmurs of aortic regurgitation and mitral stenosis.
        Boston M. & S.J. 1926; 195: 1146
        • Bland E.F.
        • Duckett Jones T.
        • White P.D.
        The development of mitral stenosis in young people with a discussion of the frequent misinterpretation of a mid-diastolic murmur at the cardiac apex.
        Am. Heart J. 1935; 9: 995
        • Gibson S.
        Eyes, hands, and ears in the diagnosis of heart disease in children.
        Pediat. Clin. North America. 1954; : 3
        • Coombs C.F.
        Rheumatic Heart Disease.
        Wood, New York1924
        • Bramwell C.
        Signs simulating those of mitral stenosis.
        Brit. Heart J. 1943; 5: 26
        • Hurst J.W.
        Some comments on auscultation of the heart. The intensity of the first heart sound at the apex.
        J. M. A. Georgia. 1957; 46: 47
        • Weinstein M.
        • Lev M.
        Apical diastolic murmurs without mitral stenosis.
        Am. Heart J. 1942; 23: 809
        • Ravin A.
        • Darley W.
        Apical diastolic murmur in patent ductus arteriosus.
        Ann. Int. Med. 1950; 37: 903
        • Fishleder B.L.
        • Medrano G.A.
        Retumbo apical en conducto arterial.
        Arch. Inst. cardiol. México. 1952; 22: 292
        • Alimurung M.M.
        • Rappaport M.B.
        • Sprague H.B.
        Variations in first apical sound simulating so-called “presystolic” murmur of mitral stenosis: Phonocardiographic study.
        New England J. Med. 1949; 241: 631
        • Nadas A.S.
        • Alimurung M.M.
        Apical diastolic murmurs in congenital heart disease.
        Am. Heart J. 1952; 3: 4
        • Nadas A.S.
        • Alimurung M.M.
        Apical diastolic murmurs in congenital heart disease.
        Am. Heart J. 1952; 3: 691
        • Currens J.H.
        • Thompson W.B.
        • Rappaport M.B.
        • Sprague H.B.
        Clinical and phono-cardiographic observations on the Flint murmur.
        New England J. Med. 1953; 248: 583
        • Hubbard T.F.
        • Dunn F.L.
        • Neis D.D.
        A phonocardiographic study of the apical diastolic murmurs in pure mitral insufficiency.
        Am. Heart J. 1959; 57: 223
        • Luisada A.A.
        • Perez Montes L.
        A phonocardiographic study of apical diastolic murmurs simulating those of mitral stenosis.
        Ann. Int. Med. 1950; 33: 56
        • Luisada A.A.
        • Haring O.M.
        • Zilli A.B.
        Apical diastolic murmurs simulating mitral stenosis. II. Graphic differentiation.
        Ann. Int. Med. 1955; 42: 644
        • Zilli A.B.
        • Gamna G.
        Evaluation of murmurs in early rheumatic heart disease.
        Am. J. Med. 1954; 17: 775
        • McKusick V.
        Cardiovascular Sound.
        Williams & Wilkins Co, Baltimore1959
        • Likoff W.
        • Geckeler G.D.
        • Gregory J.E.
        Functional mitral stenosis produced by an intra-atrial tumor.
        Am. Heart J. 1954; 47: 619
        • Luisada A.A.
        • Richmond L.
        • Aravanis C.
        Selective phonocardiography.
        Am. Heart J. 1956; 51: 221
        • Zalter R.
        • Hodara H.
        • Luisada A.A.
        Phonocardiography. I. General principles and problems of standardization.
        Am. J. Cardiol. 1959; 4: 3
        • Zalter R.
        • Luisada A.A.
        Phonocardiography. II. Appraisal and critical analysis of existing systems.
        Am. J. Cardiol. 1959; 4: 16
        • Luisada A.A.
        • Zalter R.
        Phonocardiography. III. Design of the ideal phonocardiograph.
        Am. J. Cardiol. 1959; 4: 24
        • Luisada A.A.
        • Liu C.K.
        Simple methods for recording intracardiac electrocardiograms and phonocardiograms during left or right heart catheterization.
        Am. Heart J. 1957; 54: 531
        • Braunwald E.
        • Walch G.H.
        • Morrow A.G.
        The effects of acutely increased systemic resistance on the left atrial pressure pulse: a method for the clinical detection of mitral insufficiency.
        J. Clin. Invest. 1958; 37: 35
        • Selzer A.
        • Willett F.M.
        • McCaughey D.J.
        • Feichtmeir T.V.
        Use of cardiac catheterization in acquired heart disease.
        New England J. Med. 1957; 257: 96