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The Austin Flint Murmur Phonocardiographic and Patho

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The Austin Flint Murmur Phonocardiographic and Patho The Austin Flint Murmur Phonocardiographic and Patho-anatomical Study Hideo UEDA, M. D., Tsuguya SAKAMOTO, M. D., Nobuyoshi KAWAI, M. D., Hiroshi WATANABE, M. D., Zen'ichiro UozuMI, M. D., Ryozo OKADA, M. D., Tohru KOBAYASHI, M. D., Tetsuro YAMADA, M. D., Kiyoshi INOUE, M. D., and Goro KAITO, M. D. Clinical, phonocardiographic and patho-anatomical studies were made on 15 cases with the Austin Flint murmur. The phonocardio- graphic characteristics were pointed out, and the mode of production of this murmur was explained based on the patho-anatomy of the mitral valve. Several typical cases were illustrated. INCE the last century, the Austin Flint murmur, a well-known apical diastolic rumble in aortic insufficiency,1) has been extensively debated by many authors. 2)-49) However, despite the ample arguments on the incidence, acoustic and graphic characteristics, clinical background and cardiac patho- logy, a comprehensive study with the phonocardiographic as well as patho- logic confirmation has not been attempted up to the present time. The purpose of the present study is, therefore, to investigate these figures based on the clinico-pathological observations. Particular attention was paid to search for the auscultatory and phonocardiographic characteristics of the Austin Flint murmur, and to observe whether any patho-anatomical factors seem to be responsible for the production of this murmur. MATERIAL AND METHOD Out of the autopsy cases from the Second Department of Internal Medicine, Tokyo University Hospital, 14 cases of •gisolated•h aortic insufficiency had com- plete clinical examination including phonocardiography. The cases with con- comitant •gorganic•h mitral insufficiency were not included in this series. All cases but one were male, and the age ranged from 19 to 59 with an average of 44. In all cases except one, the cause of death was congestive heart failure due to val- vular disease. An exceptional case died of acute myocardial infarction in the early stage of syphilitic aortic insufficiency and was excluded from this study because of the absence of the manifest clinical pictures of aortic insufficiency. In addition to these 13 cases, 2 autopsy cases of dissecting aortic aneurysm with the Austin Flint From the Second Department of Internal Medicine, Faculty of Medicine, University of Tokyo Tokyo. 294 Vol. 6 No. 4 AUSTIN FLINT MURMUR 295 murmur were included in this study. Both were male and aged 25 and 38, re- spectively. All 15 patients had significant aortic insufficiency and had a wide pulse pressure with undetermined diastolic blood pressure level (0mm.Hg). In all cases, auscultation was repeatedly performed and phonocardiographic investigation was made at least 2 times or more. The phonocardiograms were taken by the use of a multi-filter system phonocardiograph 50) and a dynamic microphone. During past 3 years, the phonocardiograms with same filter system were simultaneously recorded from 2 or more auscultatory areas using a photographic paper of 150mm. in width. In most cases in this study, both Low (L) and High (H) Frequency PCG were sim- ultaneously recorded from 2 areas, namely the maximal point of intensity of blow- ing and rumbling murmurs. This technique makes it easy and accurate to compare the exact time relationship and various graphic features of 2 kinds of murmur. Combined auscultatory and phonocardiographic investigation was attempted to determine the location, intensity, transmission, and all other characteristics of the Austin Flint murmur and the other auscultatory and phonocardiographic findings. The method was partly described in the previous paper. 51) For the analysis of diastolic rumble, 100 cases of proved pure mitral stenosis with sinus rhythm were utilized as a control. Patho-anatomical study was performed on the fresh specimen as well as after fixation in 20 % of Formalin. Microscopic examination was car- ried on the Hematoxylin-Eosin, Mallory's azan and Weigert van Gieson's stainings. RESULT A. Auscultatory and Phonocardiographic Study of the Austin Flint Murmur 1) Incidence: All 15 cases had this murmur , irrespective of the ex- istence of congestive heart failure. Once it was noticed, it usually continued during life. No case was encountered in whom this murmur completely dis- appeared after appropriate therapy. 2) Cardiac rhythm: Almost all cases had sinus rhythm. Prolongation of P-R interval was in only one case. Atrial fibrillation was observed trans- iently in one case and in later stage in 2 including a case of dissecting aneurysm. 3) Maximal point of intensity: In all cases, this murmur was best heard and recorded around the cardiac apex. 4) Intensity: Eight cases had the Levine's grade 43)of more than III . Relatively faint murmur was observed in 4, whereas it was extremely loud (grade V) in one. 5) Transmission: Generally, loud Austin Flint murmur transmitted widely. Nine cases had clearly recordable murmur over 2 intercostal spaces. One case showed an extreme transmission over the entire precordium . In this case, the phonocardiogram at the maximum point of the blowing murmur showed the low-pitched rumbling murmur on the Low PCG, whereas High PCG showed the blowing murmur. Jap. Heart J. J 296 UEDA, ET AL. uly, 1965 6) Quality: The Austin Flint murmur had predominantly low-pitched components. Two cases frequently revealed musical quality of this murmur as well as of the first heart sound. 7) Timing: All cases had the mid-diastolic component. Presystolic (atrio-systolic) component without unequivocal crescendo was observed in 12 cases. Two cases had no presystolic component even with the sinus rhythm. 8) Diastolic sounds: The third heart sound was recorded in all cases, but the auscultation was not able to separate clearly the third sound and mid-diastolic rumble in most cases. The atrial sound was recorded in 5 cases, but it was not clearly separable from the atrio-systolic murmur in 3 cases. A distinct mitral opening •gsnap•h was not observed, but an opening sound 52) was sometimes recorded. 9) Graphic configuration of the Austin Flint murmur: This murmur was exclusively recorded on the Low to Medium PCG and never inscribed clearly on the Medium-High to High PCG, except the case with an extra- ordinarily loud rumble. The mid-diastolic component was accompanied with the third sound and showed decrescendo character. However, this murmur frequently revealed the change in the configuration from cycle to cycle or from day to day. The atrio-systolic component had no crescendo character even with the tachycardia and normal P-R interval. 10) Graphic analysis of presystolic component: In respect to the interval between the beginning of P wave and the peak amplitude of presystolic (atrio- systolic) component of this murmur, a comparison was made between 100 cases of pure mitral stenosis and 13 cases with the Austin Flint murmur during sinus rhythm. The peak of amplitude was determined in average in many successive beats, because this point of murmur was frequently variable in com- parison to that of mitral stenosis. In mitral stenosis, the peak amplitude was usually situated just before the first sound except the cases with prolonged P-R interval. Generally speaking, the longer the P-R interval, the larger the P-peak amplitude interval (Fig. 1). Such a tendency was similarly observed in cases with the Austin Flint murmur. However, distinct difference was such that the shorter P-peak amplitude interval in cases with the Austin Flint mur- mur. 11) Phonocardiographic findings other than the Austin Flint murmur: All cases had loud blowing regurgitant diastolic murmur of severe degree. 51) Namely, this murmur had a configuration of very short crescendo and relatively short decrescendo, giving scarcely holodiastolic character in many cases. The second heart sound at the base was accentuated in many, but it was not clearly heard at the apex. The first heart sound at the apex was not accentuated in all, but it was muffled in most cases, giving low frequency Vol. 6 No. 4 AUSTIN FLINT MURMUR 297 •œ Aortic insufficiency with Austin Flint murmur •Z Pure mitral stenosis Fig. 1. Timing of the peak amplitude of the presystolic (atrio-systolic) com- ponent of the Austin Flint murmur. The interval between the beginning of the P wave and the peak amplitude (ordinate) of individual cases was plotted against the P-R interval of the electro- cardiogram (abscissa). See text. and small amplitude vibration. Aortic ejection sound was not so prominent, and all cases had aortic ejection systolic murmur, which was musical in one. Except 2, this murmur was thought to be functional and was confirmed by autopsy. 12) The Austin Flint murmur in cases of dissecting aortic aneurysm: There was no peculiarity of the apical diastolic rumble of this disease com- pared with that of pure aortic insufficiency. One case had a normal sinus rhythm and the rumble of grade III was mid-diastolic in time, and it was grade IV in another. The latter had atria] fibrillation with complete A-V block and ventricular extrasystole due to digitalis intoxication from the begin- ning of our observation. The murmur of aortic insufficiency was loud in both cases and the murmur of relative aortic stenosis was also loud, accompanying a thrill. B. Patho-anatomical Study 1) Etiology of aortic insufficiency: At autopsy, the etiology of aortic insufficiency was syphilitic in 8 including one of congenital in origin. Rheum- Jap. Heart J. J 298 UEDA, ET AL. uly, 1965 atic etiology was thought in 6 cases. Relative aortic insufficiency was observed in 2 cases of dissecting aneurysm. Two of rheumatic and one of syphilitic cases suffered from subacute bacterial endocarditis, and one case had bicuspid aortic valve with rheumatic verrucous valvulitis. 2) Mitral valve: Mitral valve revealed no stenosis even in cases of rheumatic valvulitis, namely, commissural fusion indicating stenosis of mitral orifice was not observed in all cases.
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