30 year old male referred with a murmur. Has recently immigrated from the middle East. He has always been well and moderately active, walking and doing moderate physical work without symptoms. Past history reveals no health problems or cardiovascular symptoms. Family cardiovascular history is unknown. On examination he is slim, BMI 24, and looks healthy. BP 125/70 and pulses quite easy to feel, possibly increased. On examination the heart action is not increased. You listen…
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7.1 S2 d) Cannot hear, obscured by murmur 7.2 Systole d) continuous murmur 7.3 Diastole c) continuous murmur 7.4 Impression c) patent arterial duct or d) coronary fistula
Discussion:
This patient likely has a patent arterial duct or coronary fistula which although relatively small is quite loud. The heart sounds are obscured by the continuous murmur. The systolic component of the murmur is louder than the diastolic component and is rather harsh sounding due to turbulence. The defect is large enough to create slightly increased pulses and increase the pulse pressure. It was possible to hear the murmur in this man throughout the precordium and in the left interscapular area, which is typical of an arterial duct.
An echocardiogram should identify the lesion but further imaging by CT or MRI will likely be needed in this patient. A significant shunt will enlarge the left atrium and ventricle and if these are confirmed, closure of the shunt will be advised to avoid later development of heart failure. Other more rare arteriovenous fistulae can also produce these physical findings and should be ruled out. Venous hums in the neck can produce continuous murmurs as well but are only heard at the base of the neck. They will diminish or disappear in the recumbent position, or with compression of the neck veins with a finger.
