From the IVth Medical Service, St. Eriks sjukhus, Stockholm, Sweden. (Chief: Professor Hilding Berglund, M. D.).

t3rachi;i I artery

ON THE AUSTIN FLINT MURMUR B?

Geoffrey Wadel ) , Harald Eliasch & Lars Werko.

0, Consump.

In 1862, in the course of a paper on cardiac murmurs (1); Dr. Austin Flinf, then Prof. of Medicine in the Bellevue Medical College, N. Y., posed the question: “Can an apical presystolic murmur be produced in the absence of organic disease of the mitral valve?”. He felt that it could and described two cases of aortic incompetence in which apical presystolic murmur had been audible during life and yet no disease of the mitral valve was found at autopsy. He postulated that rapid filling of the left ventricle with blood regurgitation through the aortic valve caused the leaflets of the mitral valve to be brought into apposition early in diastole and consequently the valve was closed at the time of auricular systole. The physical condition was thus analogous to that obtained with organic stenosis of the mitral orifice and a murmur of similar character was produced.

The Austin Flinf murmur is still open to debate. Although White 12)

Basal

work 15’ after work

During

Table 1. Pressures and flows at rest and on effort. A l l pressures referred to a point 5 cms. below the sternal notch with the patient semirecumbent and expressed in mm.

of mercury.

82 19 8 12 8

90 22 !) 13 ;

68 20 fi 1 1 ti

13i

157

129

76 263 cc

R2 119 101 cc

70 2913 cc

A r t + - V e n ’ C. Output C. Index O2 1 L/M I I , / M / M 2

1) i tf.

41.8 cc 6.9

39.5 cc

1) Dickinson Travelling Fellow in Medicinr. trniversity of Manchestrr. Submitted for publication May 24. 1951.

925

believes the syndrome may occur in certain cases of isolated aortic in- competence in which there is considerable enlargement of the left ven- tricle, other workers are in doubt as to its existence ( Warburg ( 3 ) , Luisada ( 4 ) ) . There can be no doubt that it is rare, and in the vast majority of cases of predominant aortic disease of rheumatic aetiology the presence of an apical presystolic murmur is indicative of an assocciated mitral lesion.

The development by Cournand of the technique of catheterisation of the pulmonary artery made possible a new approach to the diagnosis of mitral stenosis, the recognition of characteristic effects upon the dynamics of the lesser circulation (Bloomfield et al. ( 5 ) , Hickam & Cargill (61, La- gerliif & Werkii (7), Eliasch, Wade & Werkii (8) ) . Recently the opportunity arose of making such studies in a case of chronic rheumatic heart disease with aortic incompetence in which an apical presystolic murmur was ob- served in the absence of any radiological changes typical of niitral disease. Because of the uncertainty surrounding the Austin Flint syndrome, and because of its undoubted prognostic importance, this case is reported below:

Pig. I . Synchronous EGG and PhCG showing an npicnl presustol ir inurinur ( P M ) nnti 11 basul

diastol ic (DM).

CASE REPORT E. A. E., an 18 year old male clerk, was admitted to the IV Medical Service

of St. E r i k s sjukhus on the 5/2-51. Heart disease had been diagnosed following

F i g . 2. Poslero anierior and latcrul roentgenograms.

rheumatic fever at the age of 10, and h e had been short of breath on effort since a further attack of Rh. fever when 14 years old. (Functional grade 11). Examination revealed a loud diminuendo diastolic murmur maximal in the third left interspace at the sternal border. At the apex there was a soft systolic and a short presystolic bruit (Fig. 1). The mitral first sound was accentuated. Other systems were within normal limits. The 33. P. was 125/40. Radiologically the heart was not enlarged, (Volume 390 cclm2 body surface) and there was no enlargement of the left auricle (Fig. 2) . The E. C. G. was normal.

Catherisation was performed on the 8/2-51 and, in addition to basal readings, the reaction to graded work was also studied (Table 1). Pres- sures were recorded with the T y b j z r g Hansen-Warburg manometer (9 ) and cardiac output estimated by the direct Fick and dye injection methods. The mean PCV and P A pressures were within normal limits and did not rise on effort while the form of the PCV pressure curve was normal (8) . Cardiac output rose proportionately to the increase in 0 2 consumption, the arterio-venous 0 2 difference remaining within normal limits. Pressure curves under basal conditions and during work are shown in Fig. 3.

COMMENT

The character of the Flint murmur has been interpreted by various authors in differing ways. Flint described a “blubbering” murmur occurring before the first sound, and Gouley (10) and White ( 2 ) accept this as meaning a mitral presystolic bruit. Luisada ( 5) however, considers that it is either an audible auricular sound or a first sound which is crescendo or split, and that a true presystolic murmur does not occur. Refcrence to the phonocardiograin in Fig. 1 shows that in this case a true presystolic bruit was present.

927

If there is organic mitral stenosis in this case, then the normal pressures pertaining throughout the pulmonary circuit both at rest and after effort mean that it is of no haemodynamical importance. In addition the form of the PCV pressure curve is not that which we have come to associate

Fig. 3. Simultaneous tracings of pressures in the brachial artery, “pcv” and the pulmonary artery together with ECG, PhCG and respiration. Studies

are made at rest and during effort .

with mitral stenosis. Organic disease cannot, of course, be completely excluded, but we feel that it is unlikely to be present, for catheter studies in known cases of mitral disease have not hitherto yielded entirely normal results. For comparison there is shown in Fig. 4 the PCV curve from a case of mitral stenosis. Although the mean pressure is normal there is a

928

large presystolic wave which is typical of initral stenosis with sinus rhythm.

In addition to Fl in f ’ s original hypothesis of causation others have been put forward. Potclin ( 11 ) thought that it was due to whirlpool forination

Fig. ’c. Siniullaneoits lruciny of the “prv“ prrssure, ECG, PhCG cind rc~sl~ireifion in ci u i s c of iiiitrcrl s!vnosis. Note . the presNstolir

1, rcss ii ri’ r I s 1’.

when the stream of blood cntcring through the riiitral orifice niet thc regurgitant stream froni the aortic valve, but this is improbable for regurg- itation occurs predominantly in early diastole, while the Flint murmur is presystolic in time. Laubry & Pezzi (12) regarded it as a special form of gallop, the sound being produced by vibration of the ventricular wall, while Whife ( 2 ) felt that it was due to relative stenosis following dilatation of the left ventricle. More recently Gouley (10) has described a characteristic deformity of the right aortic leaflet which directed the regurgitant stream on to the anterior mitral curtain. Our data do not permit of any con- clusions on this point, but it does not suggest a rise in left auricular pressure such as might Be expected if Flint’s explanation is correct, nor was there any obvious dilatation of the left ventricle.

SUMMARY

A case of chronic rheumatic heart disease with aortic incompetence and an apical presystolic murmur is reported.

Radiological and haemodynamical studies did not reveal any evidence of mitral stenosis. The apical murmur was therefore considered to be an Aust in Flint murmur.

The nature and causation of this murmur is briefly discussed.

REFERENCES 1 . Flint, A . : “Cardiac Murmurs”. Amer. J. Med. Sci. XLIV: 29, 1862. 2. White, P. D.: “A note on the differentiation of the diastolic murmurs o f aortjc

incompetence and mitral stenosis”. Boston Med. & Sc. J . 295: 1146, 1926. 3. Warburg, I?.: Nortlisk laerebog i Intern Med. pt. IV. Copenhagen 1946. 4. Luisada, A.: “On apical sounds and murmurs in aortic incompetence”. Amer. Heart

-1. 28: 156, 194-1.

511 K’arbtirg 4 i r n i v r i r u r y t‘r,Iumc 820

5 . Bloomfield, R. A., Lauson, H. D., Cournand, A.. Breed, E. S. 8: Richards, D. W.: “Recording of right heart pressures in normal siihjects & in patients with chronic pulmonary disease L various types of cardio-vascular disrasc“. J. Clin. Invest. 25: 639, 1946.

G . Hickam, J. B. &k Cargill, W. H.: “Studies on cardiac output L pulmonary artery pressures in normals, certain cardiac-vascular diseases, and in emphysema.” J. Clin, Invest. 27: 10, 1948.

7. Lagerliif, H. & Werko, L.: “Studics on the circulation in man VI; the pulmonary capillary venous pressure”. Scand. J. Lab. Clin. Invest. -1 : 127, 1929.

8. Eliasch, H., Wade, G., & Werko, Id.: “The effects of work on the pulmonary cir - culation in mitral stenosis.” In preparation.

9. Warhurg, I?. B Tybjerg Hansen, A.: “The general theory of liquid filled manometers and its application to a new condensor manometer”. Abstract of Communication t o thc XVII international Physiological Congress, Oxford 1917.

10. Couley, H. A.: “The aortic valvular lesion associated with the Austin Flint miirrnur”. Am. Heart. J. 22: 208, 1941.

11. Potain. C.. Cliniques MGdicalcs de Charit& Paris 1894. 12. Lauhry, Ch. & Pezzi, C.: “Les rythmes de galop”. Paris 1926.