See: summary

In a short historical survey special attention is given to the studies of Einthoven, which are the bases of modern phonocardiographv. In the discussion about human hearing the possibility, of concentration on fixed frequency areas is stressed. “Ear like” or “gehörsähnliche” phonocardiography does not exist. In this investigation we applied “selective phonocardiography”. Five so-called “hihi-pass”” filters, found on empirical grounds by Maass and Weber, were used in our apparatus. The frequency characteristics are shown in fig. 3. ....

Zie: SUmmary

Gerritsen, Jan Willem,

See: summary In a short historical survey special attention is given to the studies of Einthoven, which are the bases of modern phonocardiographv. In the discussion about human hearing the possibility, of concentration on fixed frequency areas is stressed. “Ear like” or “gehörsähnliche” phonocardiography does not exist. In this investigation we applied “selective phonocardiography”. Five so-called “hihi-pass”” filters, found on empirical grounds by Maass and Weber, were used in our apparatus. The frequency characteristics are shown in fig. 3. .... Zie: SUmmar

Gerritsen, Jan Willem

ARTS repository - University of Groningen

   University of GroningenFonocardiografie. Betekenis voor de diagnostiek van enige aangeboren en verworvenhartgebrekenGerritsen, Jan WillemIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:1957Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Gerritsen, J. W. (1957). Fonocardiografie. Betekenis voor de diagnostiek van enige aangeboren enverworven hartgebreken. s.n.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 16-07-2023SUMMARYChapter  I .In a short historical survcv special attcntiorr is givcn to thc studiesof Einthoz.'en, l l 'hich are the bascs of modern phonocardiographv.In the discussion about human hcaring the possibilitr, of cor.r-t t ' r r t r i r t ion on [ ix t 'd  f requt 'ncv areas is  s t rcssed.  "Ear  l ik r "  or  "qchórs-áhnliche" phonocardiographv does not exist.In this investigation rve applied "selective phonocardiographr' ' .Five so-called "high-pass" fi l ters, found on ernperical grounds bvl,Iauss and lleber, were used in our ?rpparatus. The frequer.rclcharacteristics are shou'n in íig. 3.Chopter  I I .In sevcn paticnts rvith a severe pulrnonar,v stenosis (prcssurcgradicnt betrvecn pulmonarl, artery and right vcntricle tnore than75 mn-r mercurv) and in six paticnts rvith a modcratc or slightpulnionarv stenosis phonocardiographic studies were perforrrred(table I). In all cases the murmur startcd immediatclv aftcr thccnci of the first sounc{ and was diamond shaped. f 'hc maximum ofthe nturmtrr r,vas found in thc first half of the srstole in the slightand moderate cases. In the se\:cre cascs horvever thc maximum u'asreached in the sccond half of the systolc.-l.he murmur ended in slight and moderate stenosissecond sound (fig. +); in severe stenoses the cncl l ics aftercomponent of the sccond sound (fig. 5).The componcnts of the second sound are sep;rrated bvo.o7 sec. in severe stenoses.An auricular sound appeared in filter l{m, and higher in caseswith a pressure gradicnt of more than r oo mm mercurv betwccnthe pulmonarv arterv and right ventricle (f ig. 6). A s1'stolic clicku,as found in a case with a slight puhnonarv stenosis (f ig. 7 andf i g .  B ) .r t 2before thethe aorticmore thanB. P}rvith a tshunt. Irshaped sinterspacThe n-lsvstolc. lseconcl scIn tn'oafter the1'hcscf i r .e  psvstolic prvcntricle,c-xceeclingright-to-le;An ar.rrr'had a prei. 'r 'ntr. icle c(_t. Ingraphic fipurc pul r rD. Trrtablc  IV.third lcft( f ig .  r  7  )Fallot.In  thc( f i g .  r B )The murA d c l  ridiopathitable Vcresccnd,In tw,secn in lIn  onivcn to the studiesnocardiograPhr'.mssibilitr of con-r l ike" or "gehórs-onocardiograPhl ".rerical grounds brrs. The f requencrstenosis ( Prcssurc'cntricle t]lore thanmoderate or sliehts \\'ere Perfol-mednediatelr aftcr theThe maximum of;rstoie in thc slightthe maximum u'as;tenosis beforc theies aftcr the aorticLted br tlrtlre thand higher in casesmercurv betlvcctr. A slstolic clickrosis (f ig' 7 andB. Phonocariographic studies were performed in sevcn paticntsrvith a tetralogv of Fallot. Five of these had a large rieht-to-leftshunt. In two cases a small shunt was found (table II). A diamondshaped s1'stolic murmur was registered in the thircl or fourth ]eftinterspace.f'he maximum, of the rnurmur rvas reachecl in the micldlc of thesvstole. The murmur ended before the aortic compon(nt of thesecond sound in the cases with a marked rieht-to-lcft shunt.In two paticr)ts with a small right-toleft sh.nt the murmur c'cledaf ter  the aor t ic  component  of  the second sound ( f ig .  r r ,  rz ,  r3) .These tlvo p:rticnts had an acvanotic tetralogr. of Fallot.Fi'e p:rtic'ts, two of which had a moclerate elevation of thesvstolic pressurc eradicnt betwccn the pulmonzrn' arter\. and richtr-cntricle, had a splitt ing of thc scconcl sound with ar-r intcrvalexceedins o.o7 sec. T'his rvas also found in a paticnt with a markeclr ight- to- le f t  shunt  (pat icnt  R.  P.  (z)  f ig .  ro) .An auricular sound was rcsisterecl in three patic.ts one of whichh:rd a pressurc sradic't bctwecrr thc pulmonarv arter\. ancl righti. 'cntricle of onlr, 6o mm mercur\..c). In se'crr p;rtic*ts rvith a tri logv .f Fallot the phonocarclio-g-raphic finclings lvere similar to those obserr.ecl in cases ,, ith irpu rc  pu lmr ,n t r r  s t cnos i s .f). Tn'o patic.ts rvith a pc'tal.e' of F'allot arc clescribed intable IV. 1'he mtr'rur reached its maximum in both cases in thcthird left interspace. T'he phonocardiogram of paticnr A. t l. (r)(f ig. rJ) rvas similar to that f.uncl in cases with a tctralogr. .fl - 'a lLr t .In the phonocardiosram of patic.r A. v. ( t ) a svstolic crick(fig. rf3) occurred o.ro scc. after the beginning of the first so.nci.T'he murm.r was holos'stolic ancl sho*erl no specizrl features.A d d e n d u m: T'he phonocardiosrams oí f ive paticnts rvithidiopathic dilatation of the p.lmonary ar-terv were sho*.n intable v and vI. 1'here was a holosvstolic, oftcn somcwhat cres-cresccndo, murmur', that changed rvíth everv st,stole (fig. rg).In two patic'ts the second sound was split. A svstoric "crick' ' wassecn in t rvo pat icnts ( f ig .  zo and zr  ) .In one paticnt we observed a dilatation of the pulmona^' arte^'I  1 3and a svstolic pressure gradic't betwecr.r the pulmonarv arterv anclthe right vcntricle of r 5 mm mercurv. Thc phonocardiogram showeclthe characteristic fcarures described above (fig. z4).The phonocardiograrn however of a paricr.rt wlth a slight pul-monarv stenosis (pressure gradicnt betwec' pulmonar' arten. andrieht 'cntricle r7 mm mercur,v ), but without cli latation of thcpulmonarv arterv (fig. 25 and 26) showcd the characteristicfeatures observcd in the pure pulmonarv stenosis. \\,e are inclinecito think that the first p:rt icnt has an idiopathic cli latation of thepulmonarv artery' r. ith a relati*e pulmo'arv stenosis due to theidiopathic dilatation of the pulmonarv artcrv.It seems probable that the phonocarclic,gram enables us todistinguish betwer:. idiopathic dilatation of the p.lmona^. ansr\.and sten'tic changes of the pulmonar' val'es associatecl with amarked dilatation of the pulmonarl ' arterv ancr a small sl.stolicpressure sradicnt betrvecn the pulmonarv arte r' ancl the riehtr  c r r l r i c l e .Chapter III.F-iftecn patic'ts with aortic stenosis are cliviclcd on the basis ofthe clinical f indings in se'erc, moderate a.d slisht stenosis ítablevII ). whc' the stenosis rvas slight the murmur reached it, ,,.,o*imu-beforc the middle of the intervar betnecn the first and secondsound, and cnded o.o4 ,ssc. or more bef<tre the se concl sound( f i g .  z 7 ) .In ser.'ere stcnosis the m.ximum of the murmur occurrcd in themiddle betwecr the first and second sound or later, lvhile it c,ncledo.o2 sec.  or  less before the second souncl  ( f ig .  zB).In paticnt J. E. (f ig. zg) a reversal of the aortic and pulmolarvcomponcnt of the second sound vn,as observed.ln B patients with a broacl asccrrclins aorta a s'stolic click rvasf o u r r d  { f i c .  3 o ) .In the sphvgmographic examination .special attcntion was paidto the calculation of the crcsttime of the sphvgmogram of the caroticiarter\ '. That is the time in seconds bet.necn the startins point of theascc'ding leg of the pulse rvave and the highest poi"l Àt the mainwar''e. This time can be expressed as a perccntage of the total pulseo'cle (svstolic and diastolic). In slight a,rtic stenosis the cresitimer  r &(cpsolse(oslof+di ftharel:o f ,offii n t\,o f tnot\1regualwaTharmurter! andshorvcclqht pul^:er\ anclL c,f theacteristicinciine dn of thee to thces us tc).rÏ arterïI rvith ali srstolic:the rieht\r'as I g per ccnt or les-s, rvhile in severe stenosis the cresttimeexceeded 27 pe ' r  cent  ( f ig .  3z) .Chapter  I I : .In twentl '  out ol twentv-five paticnts with mitral stenosis it waspossible to check the phonocardiographic finclings at operation(rable vI I I  )  .\\ hcn the first sound was loud and an openin{ snep was present,the surgeon alwavs found more or less flexible r.nitral valves. f'hismade it possible to perform a satisfactorv commissurotomr'. It ispossible however that the surgeon obserr.es a minor degree ofcalcification in the marsins of the leaves.A normal or soft first sound was alwavs associatccl with the abscnceof the opening -snap. In these cases the surgeon oftcn found stiffvalves with an extcnsive calcification. The l'alves resembled acalcif ied diaphragrn r'vith a small unchangeable orif ice, rvhich usuallr 'produced regurgitation.The differcnce betwecn (Q (r,rcc) - f irst sound) and (secondsound-opening snap), converted for a preceedine R-R cyclus of o,Bsec., as proposed by Ll/ells, was correlated rvith thc size of the mitralostium as found b,v the surseon or as calculated rvith the formulact| (]orl in (f ig.3B). It appeared that there is betu,ecn -rtf and*5 an approximatelv l inear relationship betwecn the calculateddiffercnce and the size of thc mitral orif ice, whcn this is smallerthan r t/2 sqttare cm. If the orifice is more than z square cm norelationship could be detccted. This is in accordance with the findingsoï Lewis, who found that a normal ílow is possible through a mitraloffice large than e,5 square cm, rvithout elevation of the pressurein the left atrium.Whcn a svstolic murmur was found, that ended before the middleof the period betwecn the {irst and second sound, the surgeon didnot f ind resursitation.When the phonocardiogram .showed holosvstolic murmurs, markcdregurgitation was alwal's detected at operation. An opening snap isalways abscnt in these cases and the first sound is normal or soft.Than a third sound mav be observed (fig. 39). The diastolicmurmur was {requentlv praesl'stolic, in sevcn cases praesvstolice basis ofrsis (tablcmaximutnrd secondrd -qounded in thcit cucledrlmonarr't i ick u'asvas Paide carotid:rt of thche maintal Pulse'resttinlcl  1 5crcsccndo and poststolic dccrescendo, oftcn beginning some titrteaf tcr  the second sound ( í ig .  4o) .Chapter  I / .In tcn paticnts rvith a coarctatio aortae phonocardioeraphic in-vestigations u'erc rnade. In somc paticnts complicating cardizrcabnormalit ics (r 'cntricular septal defect, patcnt ductus Botall i)cxisted.' l he rnurmurs not due to these corlplicatin,q lesions could bedividcd into two groups:A. munnuls starting immcdiatelv afte r the first sound;B. murnlurs beginning solne ti lre :rfter the c'nd of the first sound.,[d. A. It is clear that a murmur, starting immcdiatelr aftcr thefirst sound is not produced in the coarctation. Its origin must beclose to the heart in the ascending aorta and or thc valves. It wasfound that the murmurs rcsistered in the second right or lcft inter-space all started immediatch' after the first sound and must havcthcir origin in the aortic valves or the aortic wall. The shape waseither diamond like or uncharacteristic. These murmurs alrvavscnded beforc the second sound ( f ig .4r) .  In  a l l  these cases thecharacteristic sphygmogram, dcscribed b,t' Donzelot, was found. Thecresttime was rB-zo per cent, that is slightly prolonged.Ad B. The other murmurs, which are registered in front and atthe back oí the thorax, all started some time after the first soundand rvere diamond shaped. The maximum was reached on anavera€ïe of o.o4 sec. after the summit of the sphygmogram of thecarotid artery. The cnd was in most cases reached after the secondsound. A murmur that reaches its maximum after the summit of thesph;-grnogram of the carotid artery' does not originate from thecoarctation itsclf, because at that moment the pressure in theaorta zit the level of the coarctation is also alreadv diminished.A murmur, which reaches its maximum so late must arise fromthose arteries, in which the pulse wave is also retardcd, that is inthc collaterals. Betwccn the bcginning and thc cnd of thcsc murmursexistecl a considerable fall of the pressure in the sphvgmoeram ofthe carotid arter\ '. These nrurmurs, which we therefore described as'-murnlurs in the collaterals" were usuallv picked up in places rvherer  i 6we coulcpreparat.to bc sosufficicntstcnosis.Thc loe-rplains rdiff icultiesin the dirtthis concerthc collatc,from the atransmissioparasternaior left intercspeciallr of'hese obheard in fr<crialctation.. ino  so tnc  t imecardiograPhic ln-,plicating cardiaccluctus Botalli )Iesions could berst sollnd lt of thc first sound'mecliatelv after theIts origin must be' the valves, It wasI right or lc{t inter-rnd and must haverall. The shaPc wasse murmurs alrr'alsall these cases the'loÍ, was found' Therrolonged.:red in {ront and atLfter the first sound;as reached on anrhvgmogram o{ theed a{ter the seconcrr the summit of theoriginate ftom tl're presstlre in thedr. diminished'te must arise from'ctardet l .  that  is  inI of these murmurs'  sPhrarnogram oIrefore described aslP in Plat cs rvherewe could feel the pulsations of a collateral vcssel. \\rhcn the resectionpreparations l 'ere studied the coarctation appeared in manv cascsto bc so narro\\r that it is hard to imagine that a stream of blood,sufficie nt to causc a registrablc murmur could pass through thestenosis.The localisation of the coarctation in thc middle of the thoraxexplains rvhv a murmur originating from the c:oarctation has greatdifficulties in reaching the thoraxw:Lll. Transmission of the murmurin the direction of the stream does not change the situation becausethis concerns onl,v the desccnding aorta. This is mainlv fi l led throLrghthe collaterals and the stream is usuallv slon'. The collaterals originatcfrom the aorta before the coarctation and do not contribute to thetransmission of the murmur. 'L-hc localisation of the collaterals wasparasternal in front of the thorax from the third to the sixth rightor left interspace and at the bai:k along the borders of the scapula,especialh' on the left side.'I'hese obsen,ations do not aeree with the opinion, that mur-murs,heard in front or at the back oí the thorax, usually arisc from thecoarctation.I  t 7

English

Fonocardiografie. Betekenis voor de diagnostiek van enige aangeboren en verworven hartgebreken

University of Groningen Digital Archive

University of Groningen

   University of GroningenFonocardiografie. Betekenis voor de diagnostiek van enige aangeboren en verworvenhartgebrekenGerritsen, Jan WillemIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:1957Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Gerritsen, J. W. (1957). Fonocardiografie. Betekenis voor de diagnostiek van enige aangeboren enverworven hartgebreken. Groningen: s.n.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 12-11-2019SUMMARYChapter  I .In a short historical survcv special attcntiorr is givcn to thc studiesof Einthoz.'en, l l 'hich are the bascs of modern phonocardiographv.In the discussion about human hcaring the possibilitr, of cor.r-t t ' r r t r i r t ion on [ ix t 'd  f requt 'ncv areas is  s t rcssed.  "Ear  l ik r "  or  "qchórs-áhnliche" phonocardiographv does not exist.In this investigation rve applied "selective phonocardiographr' ' .Five so-called "high-pass" fi l ters, found on ernperical grounds bvl,Iauss and lleber, were used in our ?rpparatus. The frequer.rclcharacteristics are shou'n in íig. 3.Chopter  I I .In sevcn paticnts rvith a severe pulrnonar,v stenosis (prcssurcgradicnt betrvecn pulmonarl, artery and right vcntricle tnore than75 mn-r mercurv) and in six paticnts rvith a modcratc or slightpulnionarv stenosis phonocardiographic studies were perforrrred(table I). In all cases the murmur startcd immediatclv aftcr thccnci of the first sounc{ and was diamond shaped. f 'hc maximum ofthe nturmtrr r,vas found in thc first half of the srstole in the slightand moderate cases. In the se\:cre cascs horvever thc maximum u'asreached in the sccond half of the systolc.-l.he murmur ended in slight and moderate stenosissecond sound (fig. +); in severe stenoses the cncl l ics aftercomponent of the sccond sound (fig. 5).The componcnts of the second sound are sep;rrated bvo.o7 sec. in severe stenoses.An auricular sound appeared in filter l{m, and higher in caseswith a pressure gradicnt of more than r oo mm mercurv betwccnthe pulmonarv arterv and right ventricle (f ig. 6). A s1'stolic clicku,as found in a case with a slight puhnonarv stenosis (f ig. 7 andf i g .  B ) .r t 2before thethe aorticmore thanB. P}rvith a tshunt. Irshaped sinterspacThe n-lsvstolc. lseconcl scIn tn'oafter the1'hcscf i r .e  psvstolic prvcntricle,c-xceeclingright-to-le;An ar.rrr'had a prei. 'r 'ntr. icle c(_t. Ingraphic fipurc pul r rD. Trrtablc  IV.third lcft( f ig .  r  7  )Fallot.In  thc( f i g .  r B )The murA d c l  ridiopathitable Vcresccnd,In tw,secn in lIn  onivcn to the studiesnocardiograPhr'.mssibilitr of con-r l ike" or "gehórs-onocardiograPhl ".rerical grounds brrs. The f requencrstenosis ( Prcssurc'cntricle t]lore thanmoderate or sliehts \\'ere Perfol-mednediatelr aftcr theThe maximum of;rstoie in thc slightthe maximum u'as;tenosis beforc theies aftcr the aorticLted br tlrtlre thand higher in casesmercurv betlvcctr. A slstolic clickrosis (f ig' 7 andB. Phonocariographic studies were performed in sevcn paticntsrvith a tetralogv of Fallot. Five of these had a large rieht-to-leftshunt. In two cases a small shunt was found (table II). A diamondshaped s1'stolic murmur was registered in the thircl or fourth ]eftinterspace.f'he maximum, of the rnurmur rvas reachecl in the micldlc of thesvstole. The murmur ended before the aortic compon(nt of thesecond sound in the cases with a marked rieht-to-lcft shunt.In two paticr)ts with a small right-toleft sh.nt the murmur c'cledaf ter  the aor t ic  component  of  the second sound ( f ig .  r r ,  rz ,  r3) .These tlvo p:rticnts had an acvanotic tetralogr. of Fallot.Fi'e p:rtic'ts, two of which had a moclerate elevation of thesvstolic pressurc eradicnt betwccn the pulmonzrn' arter\. and richtr-cntricle, had a splitt ing of thc scconcl sound with ar-r intcrvalexceedins o.o7 sec. T'his rvas also found in a paticnt with a markeclr ight- to- le f t  shunt  (pat icnt  R.  P.  (z)  f ig .  ro) .An auricular sound was rcsisterecl in three patic.ts one of whichh:rd a pressurc sradic't bctwecrr thc pulmonarv arter\. ancl righti. 'cntricle of onlr, 6o mm mercur\..c). In se'crr p;rtic*ts rvith a tri logv .f Fallot the phonocarclio-g-raphic finclings lvere similar to those obserr.ecl in cases ,, ith irpu rc  pu lmr ,n t r r  s t cnos i s .f). Tn'o patic.ts rvith a pc'tal.e' of F'allot arc clescribed intable IV. 1'he mtr'rur reached its maximum in both cases in thcthird left interspace. T'he phonocardiogram of paticnr A. t l. (r)(f ig. rJ) rvas similar to that f.uncl in cases with a tctralogr. .fl - 'a lLr t .In the phonocardiosram of patic.r A. v. ( t ) a svstolic crick(fig. rf3) occurred o.ro scc. after the beginning of the first so.nci.T'he murm.r was holos'stolic ancl sho*erl no specizrl features.A d d e n d u m: T'he phonocardiosrams oí f ive paticnts rvithidiopathic dilatation of the p.lmonary ar-terv were sho*.n intable v and vI. 1'here was a holosvstolic, oftcn somcwhat cres-cresccndo, murmur', that changed rvíth everv st,stole (fig. rg).In two patic'ts the second sound was split. A svstoric "crick' ' wassecn in t rvo pat icnts ( f ig .  zo and zr  ) .In one paticnt we observed a dilatation of the pulmona^' arte^'I  1 3and a svstolic pressure gradic't betwecr.r the pulmonarv arterv anclthe right vcntricle of r 5 mm mercurv. Thc phonocardiogram showeclthe characteristic fcarures described above (fig. z4).The phonocardiograrn however of a paricr.rt wlth a slight pul-monarv stenosis (pressure gradicnt betwec' pulmonar' arten. andrieht 'cntricle r7 mm mercur,v ), but without cli latation of thcpulmonarv arterv (fig. 25 and 26) showcd the characteristicfeatures observcd in the pure pulmonarv stenosis. \\,e are inclinecito think that the first p:rt icnt has an idiopathic cli latation of thepulmonarv artery' r. ith a relati*e pulmo'arv stenosis due to theidiopathic dilatation of the pulmonarv artcrv.It seems probable that the phonocarclic,gram enables us todistinguish betwer:. idiopathic dilatation of the p.lmona^. ansr\.and sten'tic changes of the pulmonar' val'es associatecl with amarked dilatation of the pulmonarl ' arterv ancr a small sl.stolicpressure sradicnt betrvecn the pulmonarv arte r' ancl the riehtr  c r r l r i c l e .Chapter III.F-iftecn patic'ts with aortic stenosis are cliviclcd on the basis ofthe clinical f indings in se'erc, moderate a.d slisht stenosis ítablevII ). whc' the stenosis rvas slight the murmur reached it, ,,.,o*imu-beforc the middle of the intervar betnecn the first and secondsound, and cnded o.o4 ,ssc. or more bef<tre the se concl sound( f i g .  z 7 ) .In ser.'ere stcnosis the m.ximum of the murmur occurrcd in themiddle betwecr the first and second sound or later, lvhile it c,ncledo.o2 sec.  or  less before the second souncl  ( f ig .  zB).In paticnt J. E. (f ig. zg) a reversal of the aortic and pulmolarvcomponcnt of the second sound vn,as observed.ln B patients with a broacl asccrrclins aorta a s'stolic click rvasf o u r r d  { f i c .  3 o ) .In the sphvgmographic examination .special attcntion was paidto the calculation of the crcsttime of the sphvgmogram of the caroticiarter\ '. That is the time in seconds bet.necn the startins point of theascc'ding leg of the pulse rvave and the highest poi"l Àt the mainwar''e. This time can be expressed as a perccntage of the total pulseo'cle (svstolic and diastolic). In slight a,rtic stenosis the cresitimer  r &(cpsolse(oslof+di ftharel:o f ,offii n t\,o f tnot\1regualwaTharmurter! andshorvcclqht pul^:er\ anclL c,f theacteristicinciine dn of thee to thces us tc).rÏ arterïI rvith ali srstolic:the rieht\r'as I g per ccnt or les-s, rvhile in severe stenosis the cresttimeexceeded 27 pe ' r  cent  ( f ig .  3z) .Chapter  I I : .In twentl '  out ol twentv-five paticnts with mitral stenosis it waspossible to check the phonocardiographic finclings at operation(rable vI I I  )  .\\ hcn the first sound was loud and an openin{ snep was present,the surgeon alwavs found more or less flexible r.nitral valves. f'hismade it possible to perform a satisfactorv commissurotomr'. It ispossible however that the surgeon obserr.es a minor degree ofcalcification in the marsins of the leaves.A normal or soft first sound was alwavs associatccl with the abscnceof the opening -snap. In these cases the surgeon oftcn found stiffvalves with an extcnsive calcification. The l'alves resembled acalcif ied diaphragrn r'vith a small unchangeable orif ice, rvhich usuallr 'produced regurgitation.The differcnce betwecn (Q (r,rcc) - f irst sound) and (secondsound-opening snap), converted for a preceedine R-R cyclus of o,Bsec., as proposed by Ll/ells, was correlated rvith thc size of the mitralostium as found b,v the surseon or as calculated rvith the formulact| (]orl in (f ig.3B). It appeared that there is betu,ecn -rtf and*5 an approximatelv l inear relationship betwecn the calculateddiffercnce and the size of thc mitral orif ice, whcn this is smallerthan r t/2 sqttare cm. If the orifice is more than z square cm norelationship could be detccted. This is in accordance with the findingsoï Lewis, who found that a normal ílow is possible through a mitraloffice large than e,5 square cm, rvithout elevation of the pressurein the left atrium.Whcn a svstolic murmur was found, that ended before the middleof the period betwecn the {irst and second sound, the surgeon didnot f ind resursitation.When the phonocardiogram .showed holosvstolic murmurs, markcdregurgitation was alwal's detected at operation. An opening snap isalways abscnt in these cases and the first sound is normal or soft.Than a third sound mav be observed (fig. 39). The diastolicmurmur was {requentlv praesl'stolic, in sevcn cases praesvstolice basis ofrsis (tablcmaximutnrd secondrd -qounded in thcit cucledrlmonarr't i ick u'asvas Paide carotid:rt of thche maintal Pulse'resttinlcl  1 5crcsccndo and poststolic dccrescendo, oftcn beginning some titrteaf tcr  the second sound ( í ig .  4o) .Chapter  I / .In tcn paticnts rvith a coarctatio aortae phonocardioeraphic in-vestigations u'erc rnade. In somc paticnts complicating cardizrcabnormalit ics (r 'cntricular septal defect, patcnt ductus Botall i)cxisted.' l he rnurmurs not due to these corlplicatin,q lesions could bedividcd into two groups:A. munnuls starting immcdiatelv afte r the first sound;B. murnlurs beginning solne ti lre :rfter the c'nd of the first sound.,[d. A. It is clear that a murmur, starting immcdiatelr aftcr thefirst sound is not produced in the coarctation. Its origin must beclose to the heart in the ascending aorta and or thc valves. It wasfound that the murmurs rcsistered in the second right or lcft inter-space all started immediatch' after the first sound and must havcthcir origin in the aortic valves or the aortic wall. The shape waseither diamond like or uncharacteristic. These murmurs alrvavscnded beforc the second sound ( f ig .4r) .  In  a l l  these cases thecharacteristic sphygmogram, dcscribed b,t' Donzelot, was found. Thecresttime was rB-zo per cent, that is slightly prolonged.Ad B. The other murmurs, which are registered in front and atthe back oí the thorax, all started some time after the first soundand rvere diamond shaped. The maximum was reached on anavera€ïe of o.o4 sec. after the summit of the sphygmogram of thecarotid artery. The cnd was in most cases reached after the secondsound. A murmur that reaches its maximum after the summit of thesph;-grnogram of the carotid artery' does not originate from thecoarctation itsclf, because at that moment the pressure in theaorta zit the level of the coarctation is also alreadv diminished.A murmur, which reaches its maximum so late must arise fromthose arteries, in which the pulse wave is also retardcd, that is inthc collaterals. Betwccn the bcginning and thc cnd of thcsc murmursexistecl a considerable fall of the pressure in the sphvgmoeram ofthe carotid arter\ '. These nrurmurs, which we therefore described as'-murnlurs in the collaterals" were usuallv picked up in places rvherer  i 6we coulcpreparat.to bc sosufficicntstcnosis.Thc loe-rplains rdiff icultiesin the dirtthis concerthc collatc,from the atransmissioparasternaior left intercspeciallr of'hese obheard in fr<crialctation.. ino  so tnc  t imecardiograPhic ln-,plicating cardiaccluctus Botalli )Iesions could berst sollnd lt of thc first sound'mecliatelv after theIts origin must be' the valves, It wasI right or lc{t inter-rnd and must haverall. The shaPc wasse murmurs alrr'alsall these cases the'loÍ, was found' Therrolonged.:red in {ront and atLfter the first sound;as reached on anrhvgmogram o{ theed a{ter the seconcrr the summit of theoriginate ftom tl're presstlre in thedr. diminished'te must arise from'ctardet l .  that  is  inI of these murmurs'  sPhrarnogram oIrefore described aslP in Plat cs rvherewe could feel the pulsations of a collateral vcssel. \\rhcn the resectionpreparations l 'ere studied the coarctation appeared in manv cascsto bc so narro\\r that it is hard to imagine that a stream of blood,sufficie nt to causc a registrablc murmur could pass through thestenosis.The localisation of the coarctation in thc middle of the thoraxexplains rvhv a murmur originating from the c:oarctation has greatdifficulties in reaching the thoraxw:Lll. Transmission of the murmurin the direction of the stream does not change the situation becausethis concerns onl,v the desccnding aorta. This is mainlv fi l led throLrghthe collaterals and the stream is usuallv slon'. The collaterals originatcfrom the aorta before the coarctation and do not contribute to thetransmission of the murmur. 'L-hc localisation of the collaterals wasparasternal in front of the thorax from the third to the sixth rightor left interspace and at the bai:k along the borders of the scapula,especialh' on the left side.'I'hese obsen,ations do not aeree with the opinion, that mur-murs,heard in front or at the back oí the thorax, usually arisc from thecoarctation.I  t 7

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University of Groningen Research Database

  
 University of Groningen
Fonocardiografie. Betekenis voor de diagnostiek van enige aangeboren en verworven
hartgebreken
Gerritsen, Jan Willem
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1957
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Gerritsen, J. W. (1957). Fonocardiografie. Betekenis voor de diagnostiek van enige aangeboren en
verworven hartgebreken Groningen: s.n.
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SUMMARY
Chapter  I .
In a short historical survcv special attcntiorr is givcn to thc studies
of Einthoz.'en, l l 'hich are the bascs of modern phonocardiographv.
In the discussion about human hcaring the possibilitr, of cor.r-
t t ' r r t r i r t ion on [ ix t 'd  f requt 'ncv areas is  s t rcssed.  "Ear  l ik r "  or  "qchórs-
áhnliche" phonocardiographv does not exist.
In this investigation rve applied "selective phonocardiographr' ' .
Five so-called "high-pass" fi l ters, found on ernperical grounds bv
l,Iauss and lleber, were used in our ?rpparatus. The frequer.rcl
characteristics are shou'n in íig. 3.
Chopter  I I .
In sevcn paticnts rvith a severe pulrnonar,v stenosis (prcssurc
gradicnt betrvecn pulmonarl, artery and right vcntricle tnore than
75 mn-r mercurv) and in six paticnts rvith a modcratc or slight
pulnionarv stenosis phonocardiographic studies were perforrrred
(table I). In all cases the murmur startcd immediatclv aftcr thc
cnci of the first sounc{ and was diamond shaped. f 'hc maximum of
the nturmtrr r,vas found in thc first half of the srstole in the slight
and moderate cases. In the se\:cre cascs horvever thc maximum u'as
reached in the sccond half of the systolc.
-l.he 
murmur ended in slight and moderate stenosis
second sound (fig. +); in severe stenoses the cncl l ics after
component of the sccond sound (fig. 5).
The componcnts of the second sound are sep;rrated bv
o.o7 sec. in severe stenoses.
An auricular sound appeared in filter l{m, and higher in cases
with a pressure gradicnt of more than r oo mm mercurv betwccn
the pulmonarv arterv and right ventricle (f ig. 6). A s1'stolic click
u,as found in a case with a slight puhnonarv stenosis (f ig. 7 and
f i g .  B ) .
r t 2
before the
the aortic
more than
B. P}
rvith a t
shunt. Ir
shaped s
interspac
The n-l
svstolc. l
seconcl sc
In tn'o
after the
1'hcsc
f i r .e  p
svstolic pr
vcntricle,
c-xceecling
right-to-le;
An ar.rrr'
had a pre
i. 'r 'ntr. icle c
(_t. In
graphic fi
purc pul r r
D. Trr
tablc  IV.
third lcft
( f ig .  r  7  )
Fallot.
In  thc
( f i g .  r B )
The mur
A d c l  r
idiopathi
table V
cresccnd,
In tw,
secn in l
In  on
ivcn to the studies
nocardiograPhr'.
mssibilitr of con-
r l ike" or "gehórs-
onocardiograPhl ".
rerical grounds br
rs. The f requencr
stenosis ( Prcssurc
'cntricle t]lore than
moderate or slieht
s \\'ere Perfol-med
nediatelr aftcr the
The maximum of
;rstoie in thc slight
the maximum u'as
;tenosis beforc the
ies aftcr the aortic
Lted br tlrtlre than
d higher in cases
mercurv betlvcctr
. A slstolic click
rosis (f ig' 7 and
B. Phonocariographic studies were performed in sevcn paticnts
rvith a tetralogv of Fallot. Five of these had a large rieht-to-left
shunt. In two cases a small shunt was found (table II). A diamond
shaped s1'stolic murmur was registered in the thircl or fourth ]eft
interspace.
f'he maximum, of the rnurmur rvas reachecl in the micldlc of the
svstole. The murmur ended before the aortic compon(nt of the
second sound in the cases with a marked rieht-to-lcft shunt.
In two paticr)ts with a small right-toleft sh.nt the murmur c'cled
af ter  the aor t ic  component  of  the second sound ( f ig .  r r ,  rz ,  r3) .
These tlvo p:rticnts had an acvanotic tetralogr. of Fallot.
Fi'e p:rtic'ts, two of which had a moclerate elevation of the
svstolic pressurc eradicnt betwccn the pulmonzrn' arter\. and richt
r-cntricle, had a splitt ing of thc scconcl sound with ar-r intcrval
exceedins o.o7 sec. T'his rvas also found in a paticnt with a markecl
r ight- to- le f t  shunt  (pat icnt  R.  P.  (z)  f ig .  ro) .
An auricular sound was rcsisterecl in three patic.ts one of which
h:rd a pressurc sradic't bctwecrr thc pulmonarv arter\. ancl right
i. 'cntricle of onlr, 6o mm mercur\..
c). In se'crr p;rtic*ts rvith a tri logv .f Fallot the phonocarclio-
g-raphic finclings lvere similar to those obserr.ecl in cases ,, ith ir
pu rc  pu lmr ,n t r r  s t cnos i s .
f). Tn'o patic.ts rvith a pc'tal.e' of F'allot arc clescribed in
table IV. 1'he mtr'rur reached its maximum in both cases in thc
third left interspace. T'he phonocardiogram of paticnr A. t l. (r)
(f ig. rJ) rvas similar to that f.uncl in cases with a tctralogr. .f
l - 'a lLr t .
In the phonocardiosram of patic.r A. v. ( t ) a svstolic crick(fig. rf3) occurred o.ro scc. after the beginning of the first so.nci.
T'he murm.r was holos'stolic ancl sho*erl no specizrl features.
A d d e n d u m: T'he phonocardiosrams oí f ive paticnts rvith
idiopathic dilatation of the p.lmonary ar-terv were sho*.n in
table v and vI. 1'here was a holosvstolic, oftcn somcwhat cres-
cresccndo, murmur', that changed rvíth everv st,stole (fig. rg).
In two patic'ts the second sound was split. A svstoric "crick' ' was
secn in t rvo pat icnts ( f ig .  zo and zr  ) .
In one paticnt we observed a dilatation of the pulmona^' arte^'
I  1 3
and a svstolic pressure gradic't betwecr.r the pulmonarv arterv ancl
the right vcntricle of r 5 mm mercurv. Thc phonocardiogram showecl
the characteristic fcarures described above (fig. z4).
The phonocardiograrn however of a paricr.rt wlth a slight pul-
monarv stenosis (pressure gradicnt betwec' pulmonar' arten. and
rieht 'cntricle r7 mm mercur,v ), but without cli latation of thc
pulmonarv arterv (fig. 25 and 26) showcd the characteristic
features observcd in the pure pulmonarv stenosis. \\,e are inclineci
to think that the first p:rt icnt has an idiopathic cli latation of the
pulmonarv artery' r. ith a relati*e pulmo'arv stenosis due to the
idiopathic dilatation of the pulmonarv artcrv.
It seems probable that the phonocarclic,gram enables us to
distinguish betwer:. idiopathic dilatation of the p.lmona^. ansr\.
and sten'tic changes of the pulmonar' val'es associatecl with a
marked dilatation of the pulmonarl ' arterv ancr a small sl.stolic
pressure sradicnt betrvecn the pulmonarv arte r' ancl the rieht
r  c r r l r i c l e .
Chapter III.
F-iftecn patic'ts with aortic stenosis are cliviclcd on the basis of
the clinical f indings in se'erc, moderate a.d slisht stenosis ítable
vII ). whc' the stenosis rvas slight the murmur reached it, ,,.,o*imu-
beforc the middle of the intervar betnecn the first and second
sound, and cnded o.o4 ,ssc. or more bef<tre the se concl sound
( f i g .  z 7 ) .
In ser.'ere stcnosis the m.ximum of the murmur occurrcd in the
middle betwecr the first and second sound or later, lvhile it c,ncled
o.o2 sec.  or  less before the second souncl  ( f ig .  zB).
In paticnt J. E. (f ig. zg) a reversal of the aortic and pulmolarv
componcnt of the second sound vn,as observed.
ln B patients with a broacl asccrrclins aorta a s'stolic click rvas
f o u r r d  { f i c .  3 o ) .
In the sphvgmographic examination .special attcntion was paid
to the calculation of the crcsttime of the sphvgmogram of the carotici
arter\ '. That is the time in seconds bet.necn the startins point of the
ascc'ding leg of the pulse rvave and the highest poi"l Àt the main
war''e. This time can be expressed as a perccntage of the total pulse
o'cle (svstolic and diastolic). In slight a,rtic stenosis the cresitime
r  r &
(
c
p
sol
se(
osl
of
+
di f
tha
rel:
o f ,
offi
i n t
\,
o f t
not
\1
regu
alwa
Thar
murt
er! and
shorvccl
qht pul^
:er\ ancl
L c,f the
acteristic
inciine d
n of the
e to thc
es us tc)
.rÏ arterï
I rvith a
li srstolic:
the rieht
\r'as I g per ccnt or les-s, rvhile in severe stenosis the cresttime
exceeded 27 pe ' r  cent  ( f ig .  3z) .
Chapter  I I : .
In twentl '  out ol twentv-five paticnts with mitral stenosis it was
possible to check the phonocardiographic finclings at operation
(rable vI I I  )  .
\\ hcn the first sound was loud and an openin{ snep was present,
the surgeon alwavs found more or less flexible r.nitral valves. f'his
made it possible to perform a satisfactorv commissurotomr'. It is
possible however that the surgeon obserr.es a minor degree of
calcification in the marsins of the leaves.
A normal or soft first sound was alwavs associatccl with the abscnce
of the opening -snap. In these cases the surgeon oftcn found stiff
valves with an extcnsive calcification. The l'alves resembled a
calcif ied diaphragrn r'vith a small unchangeable orif ice, rvhich usuallr '
produced regurgitation.
The differcnce betwecn (Q (r,rcc) - f irst sound) and (second
sound-opening snap), converted for a preceedine R-R cyclus of o,B
sec., as proposed by Ll/ells, was correlated rvith thc size of the mitral
ostium as found b,v the surseon or as calculated rvith the formula
ct| (]orl in (f ig.3B). It appeared that there is betu,ecn -rtf and
*5 an approximatelv l inear relationship betwecn the calculated
differcnce and the size of thc mitral orif ice, whcn this is smaller
than r t/2 sqttare cm. If the orifice is more than z square cm no
relationship could be detccted. This is in accordance with the findings
oï Lewis, who found that a normal ílow is possible through a mitral
office large than e,5 square cm, rvithout elevation of the pressure
in the left atrium.
Whcn a svstolic murmur was found, that ended before the middle
of the period betwecn the {irst and second sound, the surgeon did
not f ind resursitation.
When the phonocardiogram .showed holosvstolic murmurs, markcd
regurgitation was alwal's detected at operation. An opening snap is
always abscnt in these cases and the first sound is normal or soft.
Than a third sound mav be observed (fig. 39). The diastolic
murmur was {requentlv praesl'stolic, in sevcn cases praesvstolic
e basis of
rsis (tablc
maximutn
rd second
rd -qound
ed in thc
it cucled
rlmonarr'
t i ick u'as
vas Paid
e carotid
:rt of thc
he main
tal Pulse
'resttinlc
l  1 5
crcsccndo and poststolic dccrescendo, oftcn beginning some titrte
af tcr  the second sound ( í ig .  4o) .
Chapter  I / .
In tcn paticnts rvith a coarctatio aortae phonocardioeraphic in-
vestigations u'erc rnade. In somc paticnts complicating cardizrc
abnormalit ics (r 'cntricular septal defect, patcnt ductus Botall i)
cxisted.
' l he rnurmurs not due to these corlplicatin,q lesions could be
dividcd into two groups:
A. munnuls starting immcdiatelv afte r the first sound;
B. murnlurs beginning solne ti lre :rfter the c'nd of the first sound.
,[d. A. It is clear that a murmur, starting immcdiatelr aftcr the
first sound is not produced in the coarctation. Its origin must be
close to the heart in the ascending aorta and or thc valves. It was
found that the murmurs rcsistered in the second right or lcft inter-
space all started immediatch' after the first sound and must havc
thcir origin in the aortic valves or the aortic wall. The shape was
either diamond like or uncharacteristic. These murmurs alrvavs
cnded beforc the second sound ( f ig .4r) .  In  a l l  these cases the
characteristic sphygmogram, dcscribed b,t' Donzelot, was found. The
cresttime was rB-zo per cent, that is slightly prolonged.
Ad B. The other murmurs, which are registered in front and at
the back oí the thorax, all started some time after the first sound
and rvere diamond shaped. The maximum was reached on an
avera€ïe of o.o4 sec. after the summit of the sphygmogram of the
carotid artery. The cnd was in most cases reached after the second
sound. A murmur that reaches its maximum after the summit of the
sph;-grnogram of the carotid artery' does not originate from the
coarctation itsclf, because at that moment the pressure in the
aorta zit the level of the coarctation is also alreadv diminished.
A murmur, which reaches its maximum so late must arise from
those arteries, in which the pulse wave is also retardcd, that is in
thc collaterals. Betwccn the bcginning and thc cnd of thcsc murmurs
existecl a considerable fall of the pressure in the sphvgmoeram of
the carotid arter\ '. These nrurmurs, which we therefore described as
'-murnlurs in the collaterals" were usuallv picked up in places rvhere
r  i 6
we coulc
preparat.
to bc so
sufficicnt
stcnosis.
Thc lo
e-rplains r
diff iculties
in the dirt
this concer
thc collatc,
from the a
transmissio
parasternai
or left inter
cspeciallr o
f'hese ob
heard in fr<
crialctation.
. ino  so tnc  t ime
cardiograPhic ln-
,plicating cardiac
cluctus Botalli )
Iesions could be
rst sollnd l
t of thc first sound'
mecliatelv after the
Its origin must be
' the valves, It was
I right or lc{t inter-
rnd and must have
rall. The shaPc was
se murmurs alrr'als
all these cases the
'loÍ, was found' The
rrolonged.
:red in {ront and at
Lfter the first sound
;as reached on an
rhvgmogram o{ the
ed a{ter the seconcr
r the summit of the
originate ftom tl'
re presstlre in the
dr. diminished'
te must arise from
'ctardet l .  that  is  in
I of these murmurs
'  sPhrarnogram oI
refore described as
lP in Plat cs rvhere
we could feel the pulsations of a collateral vcssel. \\rhcn the resection
preparations l 'ere studied the coarctation appeared in manv cascs
to bc so narro\\r that it is hard to imagine that a stream of blood,
sufficie nt to causc a registrablc murmur could pass through the
stenosis.
The localisation of the coarctation in thc middle of the thorax
explains rvhv a murmur originating from the c:oarctation has great
difficulties in reaching the thoraxw:Lll. Transmission of the murmur
in the direction of the stream does not change the situation because
this concerns onl,v the desccnding aorta. This is mainlv fi l led throLrgh
the collaterals and the stream is usuallv slon'. The collaterals originatc
from the aorta before the coarctation and do not contribute to the
transmission of the murmur. 'L-hc localisation of the collaterals was
parasternal in front of the thorax from the third to the sixth right
or left interspace and at the bai:k along the borders of the scapula,
especialh' on the left side.
'I'hese 
obsen,ations do not aeree with the opinion, that mur-murs,
heard in front or at the back oí the thorax, usually arisc from the
coarctation.
I  t 7


Fonocardiografie. Betekenis voor de diagnostiek van enige aangeboren en verworven hartgebreken

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