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CONTINUOUS MURMURS IN CYANOTIC CONGENITAL HEART DISEASE

1961; BMJ; Volume: 23; Issue: 2 Linguagem: Inglês

10.1136/hrt.23.2.173

1468-201X

Mark Campbell, D C Deuchar,

Congenital Heart Disease Studies

A continuous murmur resembling that of persistent ductus arteriosus is not rare in cyanotic congenital heart disease, and patients with such a murmur present a striking and interesting clinical picture.The simple explanation that it is due to a persistent ductus is sometimes correct, but more often it is due to the blood flow through enlarged bronchial arteries.We are reporting 45 examples of such patients with an undoubted continuous murmur-27 seen among our first 670 patients with cyanotic congenital heart disease (4yo) and 18 seen subsequently.Generally the murmur was easily heard and widely conducted, and in all but four it was one of the striking physical signs.The group was certainly heterogeneous, but it seems worth giving a short clinical picture of the patients as a whole before attempting to divide them into groups.All were cyanotic by definition and nearly all had signs of right ventricular hypertrophy and a right ventricular pressure at about systemic level.Generally, the degree of cyanosis was not severe.In four patients it was very slight and three of these were originally sent up for ligation of a persistent ductus.In nearly half the others, it was only Grade 2, in one quarter it was Grade 3, and in a quarter it was severe (Grade 4).On the average, it was less severe than in Fallot's tetralogy (see Table III), and this was reflected in the number with only slight clubbing of the fingers and a relatively small increase in the hiemoglobin percentage, which was generally between 90 and 140 per cent (100% = 15 6 g.).Their disability, though varying widely and severe enough, was less than in most patients with morbus coeruleus, for most of them were in Grade 2 or 3, while with Fallot's tetralogy most are in Grade 3 or 4 (Table III).Squatting was found much less commonly than with Fallot's tetralogy.In spite of these findings many had very large hearts.In most there was a deep, sharply-defined pulmonary bay with a large "aortic" shadow, producing an exaggeration of the sabot-shaped heart (Fig. 1 and6), though in others the heart was smaller with the appearance generally accepted as common in pulmonary atresia.Angiocardiography was of the greatest value in demonstrating the pathways of the blood flow to the lungs.In many of the groups with large hearts, there was little trace of any element of the pulmonary arterial system and the blood was carried by bronchial arteries (Fig. 2 and7).In spite of this, the blood flow to the lungs was increased in several patients and we want to emphasize this group because it has not been widely recognized.There was a high incidence of a right-sided aortic arch.Most of our patients have a solitary arterial trunk with the blood flow to the lungs through a persistent ductus, through hypertrophied bronchial arteries, or through other anomalous collateral arteries, but a few have Fallot's tetralogy.We propose to discuss first the anatomical criteria for distinguishing persistent truncus arteriosus (P.T.A.) and pulmonary atresia for this explains how we are classifying our patients.These two conditions have often been confused although Vierordt made the distinction between them as long ago as 1898.