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Ernest Shackleton, an accomplished Antarctic explorer, developed a life-threatening illness during the Discovery Antarctic expedition of 1901–4. His documented signs and symptoms included inflamed gums attributed to scurvy, severe dyspnea, and exercise intolerance, presenting in a setting of nutritional deficiency. Physical examinations at a later date, also following a prolonged diet of limited fresh food, revealed a pulmonary systolic murmur. Thiamine deficiency with cardiomyopathy, either alone or subsequently exacerbated by advanced scurvy, may have been a prominent cause of Shackleton’s condition.

A 73-year-old Japanese man was admitted with an asymptomatic pulmonary artery aneurysm. However, chest X-ray and contrast-enhanced thoracic computed tomography revealed a protrusion at the second left branch that in fact was a pulmonary artery aneurysm with a diameter of 50 mm. Transesophageal echocardiography showed a bicuspid pulmonary valve, and cardiac catheterization revealed pulmonary stenosis with a pressure gradient of 45 mmHg, but no other heart diseases were noted. An extremely rare pulmonary artery aneurysm associated with an isolated bicuspid pulmonary valve was diagnosed.

Cardiac Lipomas, accounting for 10% of primary benign cardiac tumours are usually asymptomatic, although they can sometimes be associated with a plethora of manifestations. Our patient was a 16 year old asymptomatic female with marked lipomatous hypertrophy of the interventricular septum protruding into the right ventricle, diagnosed incidentally during the ECHO evaluation for a haemic systolic murmur.

Background Hypertrophic cardiomyopathy (HCM) in newborns is a rare and pathological condition with heterogeneous etiologies. Among all the different causes of HCM, hyperinsulinism is not generally reported but the relationship between hyperinsulinism and cardiac hypertrophy (CH) is known. Case presentation We report the case of cardiac hypertrophy (CH) in an Extremely Low Birth Weight (ELBW) infant who underwent insulin therapy after the onset of a persistent hyperglycemia due to parenteral nutrition (PN); the finding supports the hypothesis of a newborn’s iatrogenic hyperinsulinemia in cardiac involvement. Despite the effects of hyperglycemia on myocardial cells are well known and infants of diabetic mother may develop cardiac malformations, the consequences of an early administration of insulin in preterm infants have never been fully clarified and are often underestimated. The present case underlines the importance of a close cardiological follow-up in infants undergoing insulin infusion for an alteration in the glucose metabolism PN-related, that is a common finding in preterm infants. Conclusion: This case report, also considering the scientific literature, reiterates the importance of taking into account hyperinsulinism in the differential diagnosis of cardiac hypertrophy.

A 67-year-old female with recent hospitalization for pneumonia was transferred to our facility for high fevers and positive blood cultures for staph aureus. During her treatment for pneumonia, central venous catheter was placed. A systolic murmur was found in conjunction with fever and notable premature ventricular contractions on telemetry monitoring. Chest x-ray and transesophageal echocardiography were then performed, and a free guidewire was identified which was later successfully removed under interventional radiology.

Myxomatous mitral valve disease (MMVD) is the most common cardiac disease in dogs. It varies from dogs without clinical signs to those developing left-sided congestive heart failure, leading to death. Cavalier King Charles Spaniels (CKCSs) are particularly susceptible to MMVD. We hypothesised that within the elderly CKCS population, there is a sub-cohort of MMVD-affected dogs that do not have cardiac remodelling. The objectives of the present study were (i) to determine the prevalence and the degree of cardiac remodelling associated with MMVD, and (ii) assess the effect of age, gender, and body weight on echocardiographic status in a population of aged CKCSs. A total of 126 CKCSs ≥ 8 years old were prospectively included. They all had a physical and echocardiographic examination. A systolic murmur was detected in 89% of dogs, the presence of clinical signs was reported in 19% of them, and echocardiographic evidence of MMVD was described in 100%. Despite the high prevalence, 44.4% of the dogs were clear of echocardiographic signs of cardiac remodelling. Age was significantly associated with the presence and severity of cardiac remodelling and mitral valve prolapse. Our results showed that a proportion of elderly CKCS with confirmed MMVD did not undergo advanced stages of this pathology.

A 43-year-old male patient complained with atypical chest pain and dyspnea on exertion since six months ago. In heart physical examination, S1, S2, and III/VI systolic murmur in left sternal border was detected. In transthoracic echocardiography, mild LV enlargement with severe systolic dysfunction, EF=30% was reported. Patient was candidate for selective coronary angiography. Based on coronary angiography, Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) syndrome was confirmed and referred to cardiac surgeon to manage his condition.

In this study, we propose a model for classifying normal and abnormal sounds by extracting characteristics from abnormal heart sounds in which normal and symbolic murmurs appear. Heart sound data obtained through an electronic stethoscope are converted into mel-spectrogram images. The pre-trained Inception V3 model that carries out fine-tuning uses the mel-spectrogram image as input. Convolutional layers of fine-tuning completed Inception V3 models were used as feature extractors. A point-binary correlation analysis technique was used to select effective features for classification from the features extracted through the feature extractor. A crystal coefficient value, which is the square of the correlation coefficient value, is used for an accurate comparison between the features. We used an artificial neural network as a classifier in this experiment. Fine-tuned Inception V3 has an average accuracy of 87.7%. When 5-fold class validation is advanced by selecting the top 30 characteristics with high crystal coefficient values, the accuracy is 97.5%. These results can greatly assist physicians trying to detect a systolic murmur.

Background This case study’s novelty lies in the potential to link a new sign in pulmonary embolism diagnosis which does not increase cost but could lead to more rapid treatment. Early intervention in these cases is vital to decrease morbidity and mortality. Case presentation An otherwise healthy 20-year-old female patient presents to the emergency department for evaluation of a syncopal episode which occurred just prior to arriving to the emergency department. Patient also complains of ongoing shortness of breath while performing activities of daily living for 3 weeks. In this patient with no known valvular disease, physical exam revealed a systolic murmur heard only posteriorly. Subsequent emergency department workup revealed bilateral massive pulmonary emboli. Implications A new flow murmur heard in atypical locations could be an early sign to aid in the detection and diagnosis of pulmonary embolism. This is especially important in rural community hospitals with limited access to advanced imaging modalities.

Heart sound auscultation is a powerful and noninvasive technique for cardiac examinations. In this study, we propose a novel method for phonocardiogram (PCG) signal processing to enable automatic systolic murmur diagnosis. We formalize a series of analytical stages in this system and investigate the effectiveness of each step with real patient data. Firstly, in the heart sound segmentation step, a novel envelope is generated from short-time Fourier transform (STFT) of PCG signal to determine the positions of the first and second heart sounds. Meanwhile, the noisy cardiac cycle can be detected and deleted in this step. Then, we extract a 6 dimension feature, which can indicate the possibility of the occurrence of pathologic murmurs, by clustering the systolic STFT frames. Finally, a support vector machine (SVM) based classifier is trained to distinguish between heart sounds with and without murmurs. The proposed diagnostic system is evaluated by repeated random sub-sampling in an open PCG database and the results show a relatively high accuracy, sensitivity and specificity of 93.91±6.51%, 93.00±7.48% and 100% respectively for the detection of PCGs with systolic murmur.

Bottom line You are presented with a mature feline patient with a peracute onset of tachypnoea and non-ambulatory paraparesis. The cat is hypothermic, with a sternal systolic murmur and cold, stiff hindlimbs with pale cyanotic nail beds and poorly palpable hindlimb pulses. You provide oxygen therapy, diuretics and analgesia and perform a cardiac ultrasound, which identifies ventricular myocardial thickening and left atrial enlargement consistent with hypertrophic cardiomyopathy (HCM). You diagnose the cat with a cardiogenic feline arterial thromboembolism (FATE). Your clients are keen to explore treatment for the patient and, as part of this, you plan to instigate antiplatelet therapy to reduce the likelihood of a second event. However, there is no licensed antiplatelet therapy for cats. A colleague has always used aspirin, but you are uncertain if there is any evidence to support its use. In [cats with cardiogenic thromboembolism], is treating with [aspirin] associated with a better outcome [reduced risk of arterial thromboembolism or death] compared with [alternative treatments, no treatment or placebo]? The search strategy is available as a supplement to this article on Vet Record ’s website at http://veterinaryrecord.bmj.com/content/185/12/376 ### Supplementary data [vetrecl5690supp001.docx]

Aortic stenosis [AS] is set on the forth place of all cardiovascular disease in western world. Severe aortic stenosis [SAS] is one of the most common disease that in treatment demand cardiac surgery—replacement of native aortic valve with mechanical or biological prosthesis in our environment. SAS is often a consequence of a relapsed rheumatic heart disease. This paper present the possible modality of diagnosis SAS. Testing was done on 107 samples, 70 samples were SAS, and the rest of 37 were patients who were sent to some another examination, after ultrasound was done and diagnosis of SAS was excluded. In this paper, the application of basic kind of ANN architecture—the feedforward networks with backpropagation training—is explained, since this structure is able to perform nonlinear multiple regressions in a reliable manner, avoid overfitting. Dataset consists of 12 parameters as shown in Table X; sex, age, dizziness/loss of consciousness, dyspnoea, palpitation, systolic murmur of AS, EF, AV morphology, AVVmax, AVPGmean, AVPGmax, Area. Although limited number of data were present in this study, such automated systems can be used as assistant tool during diagnosis in real-time clinical settings. In the future it is planed to test and use this automated system for classification of aortic stenosis.

This 59 year-old woman had echocardiographic signs of HOCM, but for three times her echo interpreted as mild aortic valve stenosis.

Crisscross heart is a rare cardiac malformation characterized by crossing of the inflow streams of the two ventricles due to a twisting of the heart about its long axis. The developmental mechanisms and causes of crisscross heart remain unknown. Neonates present with cyanosis and a systolic murmur. In this study, we report a case of crisscross heart with situs inversus, concordant atrioventricular and ventriculo arterial connection with ventricular septal defect and pulmonary stenosis, and review the literature on this rare cardiac malformation.

Congenital aneurysm of the right atrial appendage is a rare cardiac anomaly with only a few reported cases in the literature. Most of the cases involved adults in their third decade of life. We report a case of congenital aneurysm of the right atrial appendage in a newborn, who initially presented with jaundice and incidentally discovered systolic murmur. The diagnosis was established by enhanced CT scan of the chest and echocardiography that also showed atrial septal defect (ASD) and multiple ventricular septal defects (VSDs). Because of its rare occurrence, diagnosis is difficult and the symptoms may be confused with other causes of right atrial dilation such as Ebstein's anomaly.

Gustav Mahler (1860-1911), a renown Austrian composer, died of subacute bacterial endocarditis, when antibiotic treatment was not yet available. Earlier in his life, he developed a mitral stenosis with systolic murmur which was a legacy of frequent throat infections and rheumatic fever which he had as a child. This condition was diagnosed accidentally when he was age forty-seven. Throughout his adult life, however, Mahler was asymptomatic and became a very successful conductor and musical director, as well as a prolific composer. His preoccupation with fate and death was notorious, probably having its roots in many deaths of his young siblings. The fatal blow came in a form of betrayal by his beloved wife, Alma, who had a love affair with a younger man. This sudden abandonment constituted a severe emotional stress, which superimposed on other past and present adverse events in his life, weakened his immune system. He developed bacteraemia-cum-endocarditis and finally succumbed to a cruel fate, a theme that repeatedly appears in his music.Key wordsMahler, endocarditis, betrayal, immune system, fate

We present a scenario with multiple valvular pathologies where the next management step was unclear. 79-year-old women with history of moderate aortic stenosis presented with progressively worsening dyspnea and dizziness for 1 week. Physical examination was remarkable for 4/6 systolic murmur

A 22-day-old boy born to a 21-year-old gravida 1, para 1 mother was admitted to our hospital for routine newborn examination. On physical examination, any clinical abnormality or malformations were not observed except 1/6 systolic murmur. A well-demarcated membranous structure was confirmed by echocardiography which was starting from left ventricular apex, extending to the mitral chords including papillary muscles in apical four-chamber and parasternal long-axis examination. This structure was considered as a variant of left ventricular noncompaction. The patient is still being followed up in our pediatric cardiology department.

Extrinsic pulmonary artery stenosis caused by anterior mediastinum teratoma presenting with an ejection systolic murmur is a rare phenomenon. Till date, 15 cases have been reported (inclusive of this case) in the English literatures. Herein we report a 20 year old female with extrinsic pulmonary artery stenosis because of compression by an anterior mediastinal teratoma with a loud ejection systolic murmur. The case report aims to highlight the awareness of such rare presentation of anterior mediastinal teratomas that may mimic congenital valvular heart diseases among clinicians.

The diagnosis of aortic stenosis (AS) is reached through clinical and instrumental assessment of patients [1]. The symptomatic forms are characterized by angina, dyspnea, and syncope, but the diagnostic suspicion can be supported by the presence of typical physical signs, such as harsh diamond-shaped systolic murmur, often matched by a more intense fremitus along the right upper sternal margin and irradiated to the neck, parvus et tardus pulse, fourth sound, and attenuation or disappearance of the aortic component of the second sound. A complete picture of heart failure can be found where a systolic murmur is often faint or lacking. In asymptomatic forms, physical findings can be the only evidence of aortic valve (AV) disease. With regard to instrumental examinations, standard electrocardiogram (ECG) can highlight signs of left ventricular hypertrophy. However, even in the more severe forms of AS, ECG may not show any alteration.

1. A 5-year-old boy with a history of speech delay. He still does not know his colors or shapes. He has no significant past medical history. He is not any treatment. During your exam, he is friendly and loquacious. You heard a systolic murmur that radiates to the neck. He has several dysmorphic features, including a long philtrum and prominent lips with an open mouth. What is the most likely diagnosis? A. Fragile X syndrome B. William’s syndrome C. Velocardiofacial defect D. Mitochondrial disorder E. Down’s syndrome

It is a strong tradition to introduce cow’s milk (CM) early in infancy. There are reports of various deleterious health effects of CM in infancy. We describe an asymptomatic, well-thriving infant who was exclusively fed with CM and had severe iron deficiency anemia. An eleven-months-old infant during the consultation for fever was found to have severe pallor. Except for systolic murmur, she had a normal systemic examination. Hemoglobin was 2.2 gm/dl, her RBC count, volume and hemoglobin concentration were low. Iron studies done showed a severe iron deficiency state. She was given packed cell transfusions; iron supplements were initiated. Introduction of complementary foods rich in iron is imperative as iron stores begin to deplete at four to six months of age. Initiation of CM early in infant feeding can lead to very severe anemia which can be mitigated by CM fortification, iron supplementation in infants.

Present recommendations by the US Food and Drug Administration advise that patients with prolactinoma treated with cabergoline should have an annual echocardiogram to screen for valvular heart disease. Here, we present new clinical data and a systematic review of the scientific literature showing that the prevalence of cabergoline-associated valvulopathy is very low. We prospectively assessed 40 patients with prolactinoma taking cabergoline. Cardiovascular examination before echocardiography detected an audible systolic murmur in 10% of cases (all were functional murmurs), and no clinically significant valvular lesion was shown on echocardiogram in the 90% of patients without a murmur. Our systematic review identified 21 studies that assessed the presence of valvular abnormalities in patients with prolactinoma treated with cabergoline. Including our new clinical data, only two (0·11%) of 1811 patients were confirmed to have cabergoline-associated valvulopathy (three [0·17%] if possible cases were included). The probability of clinically significant valvular heart disease is low in the absence of a murmur. On the basis of these findings, we challenge the present recommendations to do routine echocardiography in all patients taking cabergoline for prolactinoma every 12 months. We propose that such patients should be screened by a clinical cardiovascular examination and that echocardiogram should be reserved for those patients with an audible murmur, those treated for more than 5 years at a dose of more than 3 mg per week, or those who maintain cabergoline treatment after the age of 50 years.

A 20-day-old girl was referred to our clinic for systolic murmur, cyanosis, and dyspnoea with feeding. Echocardiography revealed an atretic aortic valve. CT angiography scan revealed that the left common carotid artery originated from the distal main pulmonary artery. The plan was patent ductus artriosus stenting and bilateral pulmonary artery banding and then follow-up for any possible future intervention.

Cardiac auscultation is a technique of listening to heart sounds. Any abnormality in the heart sound may indicate some problem in the heart. In this paper, the phonocardiogram (PCG) signal i.e. the digital recording of the heart sounds has been studied and classified into three classes namely normal signal, systolic murmur signal and diastolic murmur signal. Total number of samples used for this study are 144 out of which 60 are normal signals, 45 are diastolic murmur signals and 39 are systolic murmur signals. Various features have been extracted for the classification. A total of 28 features have been extracted and then reduced to 7 most significant features using feature reduction technique. The selected features have been used to classify the signal into various classes using classifiers. The classifiers which have been used in this study are k-NN (k Nearest Neighbour) , fuzzy k-NN and Artificial Neural Network (ANN) . Both k-NN and fuzzy k-NN as classifiers have the highest accuracy of 99.6%.

The following report describes the case of newborn girl with an asymptomatic systolic murmur, which on imaging revealed a nearly obstructive mass in the left-ventricular outflow tract. The mass was resected and found to be consistent with a rhabdomyoma. Here, we describe the pathologic and clinical characteristics of this tumor.

One hundred years ago, from October 1915 to April 1916, Sir Ernest Shackleton and his men were forced to camp on ice floes in the Weddell Sea after the Endurance was crushed and sank. After escaping from the ice in three small open boats, the crew of the Endurance spent six months living under two of the boats on Elephant Island, while Sir Ernest with five companions sailed 800 miles in the third, and made the first crossing of the mountains and glaciers of South Georgia. The Endurance expedition was the third of four expeditions towards Antarctica undertaken by Sir Ernest between 1901 and 1922 and was the only one during which he did not suffer a physical breakdown. We believe that his breakdowns were the result of a congenital cardiac defect. The evidence rests mainly on diary entries made by Dr Eric Marshall, the medical officer on Shackleton’s second expedition to the Antarctic (1907–1909) in the Nimrod. On 20 January 1908, Dr Marshall wrote in his diary ‘Heard S was very unwell after pulling on a rope. Will not hold myself responsible until he allows me to examine him. Something wrong?’. As medical officer, Dr Marshall was able to insist on an examination and on two occasions found a ‘pulmonary systolic murmur’. Shackleton, Marshall, Wild and Adams sledged south, discovered the Beardmore Glacier and the Polar plateau, but realising they would perish from starvation if they carried on, turned back when about 100 miles from the Pole. Back on the Beardmore, some 380 miles from base, Dr Marshall wrote ‘Shacks collapsed after dinner tonight’, and the next day ‘Sh very unwell, walked by the sledge all day – Midday-Pulse on march thin & thready, irregular about 120’. However, Shackleton recovered within a few days, and was one of the strongest of the party by the end of the journey, performing a forced march of thirty miles with Frank Wild to prevent the Nimrod leaving without them. As well as the two episodes recorded by Dr Marshall, Sir Ernest suffered a breakdown in 1903, during his first Antarctic expedition in the Discovery. He was unable to pull the sledge, due to breathlessness and weakness, towards the end of a sledge journey southwards with Robert Scott and Edward Wilson. Shackleton’s collapse was attributed to scurvy and ‘a sort of asthma’, and he was invalided home against his will. Dr James McIlroy, medical officer on Shackleton’s third and fourth expeditions, told of two other incidents, one in 1919, during an expedition to Spitzbergen ‘ – when he [Shackleton] changed colour very badly – he had a very bad bout that time but he wouldn’t undress and let me listen to his heart’, and a similar episode in 1922 on Shackleton’s last expedition. Figure 1. Frank Hurley (L) and Sir Ernest Shackleton on an ice-floe in the Weddell Sea. Image provided by the Scott Polar Research Institute, University of Cambridge.

A 30-year-old man with a history of fever, systolic murmur over the apex and NYHA III heart failure symptoms was evaluated for suspected endocarditis. Transthoracic echocardiography (TTE) revealed ...

A 20-month-old infant was admitted for further evaluation when found to have a systolic murmur and shortness of breath for 10 months. Physical examination revealed blood pressure of right upper limb was 100-mm Hg and a 30-mm Hg pressure gradient with the right lower limb. Chest X-ray showed a convex contour of the right superior mediastinum …

Cutis laxa type II (MIM 219200) is a rare congenital disorder, first described by Debre et al. in 1937. During the period from 1937 to 2008, there have been 34 (25 females and 9 males) well-documented published cases of this rare disorder. In 2009, I reported the thirty fifth case of this disorder and I also reviewed the previously published and thirty four well documented cases. A dysmorphic girl was referred at the age of Four years (early April 2016) because of skin abnormality and delayed speech. The girl had cutis laxa with redundant loose skin present from birth. This skin abnormality was evident on the limbs and abdomen. Dysmorphic facial feature included, broad and depressed nasal bridge, and the eyes were wide set with downslanting palpebral fissures. Examination of the cardiovascular system was normal except for the presence of a systolic murmur. Echocardiography revealed the presence of a small atrial septal defect. In this paper, I am reporting the 36th case of Cutis laxa (Debre type) which is the first case to be associated with atrial septal defect.

A 70-year-old female presented with a new systolic murmur and shortness of breath three years after undergoing aortic root replacement using a 27-mm Medtronic Freestyle® stentless full root bioprosthesis (Medtronic, Inc., Fridley, Minnesota, USA). A large complex aortic root pseudoaneurysm was identified on contrasted computed tomography of the chest and transesophageal echocardiogram. We describe the redo aortic root replacement using a customized Dacron tube/valve composite graft with a proximal "skirt" and a modified Cabrol technique.

Straight back syndrome (SBS) is a deformed thoracic spine disease sometimes considered as a pseudo-heart disease because its pathology can prominently affect the normal function of the heart system. SBS patients often present with signs and symptoms that are similar to some cardiac diseases that hide those of the thoracic spine. 1,2 Consequently, SBS has become the one of the most common misleading conditions in cardiology. Investigations for SBS are frequently performed in patients with an abnormal systolic murmur with no evidence of any cardiac-related cause. This article will detail the importance of the straight back syndrome in diagnostic cardiology and demonstrate a case with Magnetic Resonance Imaging.

We present the case of a 74-year-old man with progressive left-sided pulsatile tinnitus, mainly at rest, and exercise-induced heaviness of the left arm. Clinical examination revealed a midfrequency systolic murmur located in the left upper chest region and differing systolic blood pressures between

Scimitar Syndrome is a rare entity within congenital heart disease. The clinical presentation may be insidious and associated with a number of cardiopulmonary anomalies. A 47 year old male presented with progressive exertional dyspnea, palpitations, and a new systolic murmur in the setting of known

At the recent annual meeting of the British Heart Valve Society, an invited speaker asked: Why has Aortic Stenosis become so complicated? This rhetorical question was posted on Twitter and liked and retweeted several hundred times. Until recently, aortic stenosis was perceived as a relatively simple heart valve disorder. The diagnosis was straightforward—hear a systolic murmur, demonstrate a withdrawal gradient on cardiac catheterisation or an increased velocity on echocardiography and the diagnosis was complete. If the patient was symptomatic, they were referred for the only available treatment—surgical aortic valve replacement. The surgeon saw them in the clinic and they were listed for surgery. If aged ≥70, then they received a tissue prosthesis, if aged

An asymptomatic 25-year-old woman with no relevant medical history was referred for an echocardiogram in the context of a systolic murmur. This examination revealed a ventricular septal defect. The transoesophageal echocardiogram showed not only a restrictive perimembranous ventricular septal defect with a left to …

An 81-year-old lady presented at the cardiology outpatient clinic with a 6-month history of atypical chest discomfort, systemic hypertension, and hyperlipidaemia. The patient had been on bisoprolol, aspirin, and valsartan for years. Physical examination showed grade 2/6 systolic murmur at left sternal border. ECG revealed marked left-axis deviation and incomplete left bundle …

In this chapter, cases of mitral leaflets prolapse, flail, annulus calcification, rheumatic heart disease, and systolic anterior motion received mitral repair or replacement are presented.

Total anomalous pulmonary venous return (TAPVR) can be divided into four anatomic groups: (1) supracardiac (Fig. 28.1), (2) cardiac, (3) infracardiac, and (4) mixed. Also, it can be divided into two physiologic types: nonobstructed and obstructed.

Hemolysis after percutaneous device closure of ventricular septal defect (VSD) is a rare complication that can be conservatively managed in the majority of cases. However, surgery or transcatheter occlusion may be necessary. Presently described is the successful treatment of hemolysis that developed after implantation of the Nit-Occlud Lê VSD coil, using the Amplatzer Duct Occluder II (ADO II) in a patient with aneurysmatic perimembranous VSD. Systolic murmur and symptoms immediately disappeared after the procedure.

Diagnosis of congenital cardiac defects is challenging, with some being diagnosed during pregnancy while others are diagnosed after birth or later on during childhood. Prompt diagnosis allows early intervention and best prognosis. Contemporary diagnosis relies upon the history, clinical examination, pulse oximetery, chest X-ray, electrocardiogram (ECG), echocardiography (ECHO), computed tomography (CT) and cardiac catheterization. These diagnostic modalities reliable upon recording electrical activity or sound waves or upon radiation. Yet, congenital heart diseases are still liable to misdiagnosis because of level of operator expertise and other multiple factors. In an attempt to minimize effect of operator expertise this paper built a classification model for heart murmur recognition using Hidden Markov Model (HMM). This paper used Mel Frequency Cepestral coefficient (MFCC) as a feature and 13 MFCC coefficients. The machine learning model built by studying 1069 different heart sounds covering normal heart sounds, ventricular septal defect (VSD), mitral regurgitation (MR), aortic stenosis (AS), aortic regurgitation (AR), patent ductus arteriosus (PDA), pulmonary regurgitation (PR), and pulmonary stenosis (PS). MFCC feature used to extract feature matrix for each type of heart sounds after separation according to amplitude threshold. The frequency of normal heart sound (range= 1Hz to 139Hz) was specific without overlap with any of the studied defects (ranged= 156-556Hz). The frequency ranges for each of these defects was typical without overlap according to examined heart area (aortic, pulmonary, tricuspid and mitral area). The overall correct classification rate (CCR) using this model was 96% and sensitivity 98%. This model has great potential for prompt screening and specific defect detection. Effect of cardiac contractility, cardiomegaly or cardiac electrical activity on this novel detection system needs to be verified in future works.

Patient initials or identifier number HCT ### Relevant clinical history and physical exam A 57-year-old man, known hypertension, and smoker. He presented with worsening angina for 1 month and was referred to us for a coronary angiogram. PE noted displaced apex beat with a systolic murmur.

A 17-month-old albino, castrated male domestic ferret ( Mustela putorius furo ) was presented for evaluation of a heart murmur. The murmur was first auscultated when the ferret was 12 weeks of age, coinciding with its first known evaluation by a veterinarian. At the time of diagnosis, the ferret was reported to have mild exercise intolerance. The clinical findings on the ferret were within normal limits other than a right parasternal systolic murmur (grade 4/6) that radiated to the left parasternal region. The ferret was not receiving any medications. All 4 features of tetralogy of Fallot (TOF) were identified with echocardiography. Thoracic radiographs were suggestive of TOF with mild right-sided enlargement of the cardiac silhouette and small pulmonary vasculature. A serum biochemistry profile and complete blood count were within the reference ranges for domestic ferrets. At that time atenolol (3.25 mg, every 24 hours, orally) was prescribed to treat the clinical condition of the animal. At a 1-week follow-up examination, the patient's heart rate had decreased from 240-300 beats per minute to 180-260 beats per minute. The owner reported that the ferret was sleeping more frequently during the first week of therapy but had normal activity when awake. At a 5-month recheck examination, the patient was reported to be completely normal at home. This is the first case report of TOF in a ferret.

Ultrasound applications in peri-operative medicine have become common place in modern anaesthesia practice. Anaesthetists have performed transoesophageal echocardiography in cardiac and selected non-cardiac surgery for over two decades. We aimed to assess the indications, impact on clinical management and accuracy of focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period. One hundred and seventy patients over a 3-year period had a focused transthoracic echocardiogram. Adequate images to answer the clinical question were obtained in 167 out of 170 patients (98%). The undifferentiated systolic murmur was the commonest indication (98 out of 170, 58%). Some degree of aortic stenosis was present in 47 out of 170 (26%) of patients; mitral valve disease (30 out of 170 (18%)) and pulmonary hypertension (25 out of 170 (14%)) were also common. Changes in peri-operative management occurred in 140 out of 170 (82%) patients and major findings correlated with a formal cardiology transthoracic echocardiogram in 52 out of 57 (92%) patients. Focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period accurately detects major cardiac pathology and significantly alters peri-operative management.

A 54-year-old male presented with symptoms of dyspnoea, and oedema of the lower extremities. Transthoracic echocardiography (TTE) revealed secondum-type atrial septal defect (ASD). He successfully received a 30-mm Amplatzer ASD closure device percutaneously. Echocardiography immediately after the procedure and the next day showed a well-positioned device. He was discharged the next day on 100 mg aspirin daily and warfarinisation due to atrial fibrillation. A month later, he revisited the hospital due to recurrence of dyspnoea and a grade 2 systolic murmur was heard on the left parasternal border. A chest X-ray showed abnormal location of the closure device and TTE revealed re-appearance of the ASD and an embolised Amplatzer device in the left ventricular outflow tract (LVOT) with partial obstruction. He requested surgery to remove the Amplatzer device and received an ASD patch repair, tricuspid valve repair and modified Maze operation concurrently. He is now in routine follow up without any other complications.

Rationale: Ventricular septal defects are the most common congenital heart defect in children. As this method avoids sternotomy, the post-procedural morbidity is lower. However, transcatheter closure of perimembranous ventricular septal defects are still associated with complications such as arrhythmia (particularly, Atrioventricular Block), device embolization, atrioventricularvalve and/or aortic valves regurgitation, residual shunts. Some complications can be life threatening and require urgent surgical intervention. Patient concerns: An 32-months-old boy was admitted for a significant precordial systolic murmur. The patient underwent transcatheter perimembranous ventricular septal defects closure. 12 months later, Transthoracic echocardiography revealed the device displaced, 4 mm shunt acrocss the ventricular septum and moderate tricuspid regurgitation detected. Diagnosis: According to the echocardiography result, the patient was diagnosed with displacement of the ventricular septal defect occluder and tricuspid regurgitation. Interventions: After the diagnosis, the patient underwent removal of the ventricular septal defect occluder and closure of the perimembranous ventricular septal defect. Outcomes: The post-operative recovery was uneventful. One year post-procedural follow-up transthoracic echocardiography showed there was no residual shunt and no tricuspid regurgitation. Lessons: Transcatheter closure of Ventricular septal defects is an attractive alternative to surgery in simple perimembranous ventricular septal defects. Proper follow-up should be emphasized to the patient.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T18:56:23Z No. of bitstreams: 1 S0102-09352010000300010.pdf: 461773 bytes, checksum: b675aadc8f807ce7a2c51a92dac4cb3d (MD5) Made available in DSpace on 2013-08-22T18:56:23Z (GMT). No. of bitstreams: 1 S0102-09352010000300010.pdf: 461773 bytes, checksum: b675aadc8f807ce7a2c51a92dac4cb3d (MD5) Previous issue date: 2010-06-01 Made available in DSpace on 2013-09-30T19:50:15Z (GMT). No. of bitstreams: 2 S0102-09352010000300010.pdf: 461773 bytes, checksum: b675aadc8f807ce7a2c51a92dac4cb3d (MD5) S0102-09352010000300010.pdf.txt: 16748 bytes, checksum: bab8c215b9910c322a345512dcfc8462 (MD5) Previous issue date: 2010-06-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T13:14:11Z No. of bitstreams: 2 S0102-09352010000300010.pdf: 461773 bytes, checksum: b675aadc8f807ce7a2c51a92dac4cb3d (MD5) S0102-09352010000300010.pdf.txt: 16748 bytes, checksum: bab8c215b9910c322a345512dcfc8462 (MD5) Made available in DSpace on 2014-05-20T13:14:11Z (GMT). No. of bitstreams: 2 S0102-09352010000300010.pdf: 461773 bytes, checksum: b675aadc8f807ce7a2c51a92dac4cb3d (MD5) S0102-09352010000300010.pdf.txt: 16748 bytes, checksum: bab8c215b9910c322a345512dcfc8462 (MD5) Previous issue date: 2010-06-01 Na avaliação da dispneia pós-exercício em uma cadela de 10 meses de idade, não castrada e sem raça definida, foi detectado sopro sistólico leve grau II/VI. A comunicação entre a aorta ascendente e o tronco pulmonar, observada pela presença de fluxo contínuo logo abaixo das valvas semilunares, à ecoDopplercardiografia, foi confirmada pela cirurgia. Após o procedimento cirúrgico, a cadela apresentou boa condição clínica e ausência de dispneia mesmo ao exercício. Ressalta-se a importância do diagnóstico precoce e preciso para o sucesso terapêutico. Este é o primeiro relato brasileiro dessa rara doença e a única cirurgia, bem sucedida, descrita na literatura veterinária consultada. A 10-month-old intact female mixed breed dog was referred for evaluation of exercise-induced dyspnea and a low grade II/VI systolic murmur was detected. The communication between ascending aortic and pulmonary trunk was observed by detecting a continuous flow just above the semilunar valves on echoDopplercardiography and attested by surgery. After the surgical procedure, the dog was presented in good clinical conditions without exercise-induced dyspnea, reflecting the importance of an early and accurate diagnostic for the therapeutic success. This is the first Brazilian report of this rare congenital disease and the unique well succeed surgery in the veterinary literature. UNESP Faculdade de Ciências Agrárias e Veterinárias UF UNESP Faculdade de Ciências Agrárias e Veterinárias