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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.

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.

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

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.

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.

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

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.

Scimitar syndrome is a rare congenital anomaly that can make pregnancy a complicated situation to deal with. A 29 year old women, 30 weeks pregnant, comes to the emergency room with complaints of chest pain and difficulty breathing. She has no known past medical history. A loud 4/6 systolic murmur

Murmurs were described first by Laennec in 1819, after which the significance of a murmur became a matter of debate. By the late 19th century, many physicians regarded systolic murmurs as "organic," whereas others believed that they were often "functional." Samuel Levine became a central figure in separating functional from organic systolic murmurs. Freeman and Levine's 1933 study of 1,000 "noncardiac" subjects determined the frequency, cause, and significance of systolic murmurs. Murmurs were rated on a scale of 1 to 6 grades of intensity. Approximately 20% of their patients had grade 1 or 2 systolic murmurs. Hypertension, fever, tachycardia, and anemia were common factors, and the murmurs were considered functional because they would often disappear when these causes were controlled. Of 19 subjects with grade 3 or 4 murmurs, all were determined to have organic heart disease or anemia. Thus, louder systolic murmurs were found to be a significant finding, as were the cause, location, and effects of posture. They concluded that systolic murmurs often have an explanation and that their grade can be useful in the diagnosis and prognosis. They cautioned that a loud systolic murmur did not necessarily indicate a bad prognosis or even serious heart disease. Levine's system of grading a systolic murmur is valuable and persists into the 21st century.

A novel method for segmentation of heart sounds (HSs) into single cardiac cycle (S"1-Systole-S"2-Diastole) using homomorphic filtering and K-means clustering is presented. Feature vectors were formed after segmentation by using Daubechies-2 wavelet detail coefficients at the second decomposition level. These feature vectors were then used as input to the neural networks. Grow and Learn (GAL) and Multilayer perceptron-Backpropagation (MLP-BP) neural networks were used for classification of three different HSs (Normal, Systolic murmur and Diastolic murmur). It was observed that the classification performance of GAL was similar to MLP-BP. However, the training and testing times of GAL were lower as compared to MLP-BP. The proposed framework could be a potential solution for automatic analysis of HSs that may be implemented in real time for classification of HSs.

Complex congenital heart pathologies can often pose a management challenge. 27 yr old man with history of hypertension presented with fever of 3 week duration. Physical exam revealed 4/6 systolic murmur, and upper-lower extremity BP difference of 58 mmHg. TEE showed perforated anterior mitral

Hypertrophic cardiomyopathy (HCM) may remain clinically silent and undiagnosed until patients reach advanced age. We describe 2 older patients with previously undetected and probable late-onset HCM whose preoperative cardiac examination revealed only the presence of a systolic murmur. Both patients were diagnosed with HCM by perioperative echocardiography. We provide an algorithm for the evaluation of murmurs detected during the preoperative anesthesia evaluation, with emphasis on the clinical characteristics of HCM, and we discuss the perioperative management of these patients. In addition, recent findings concerning the natural progression of HCM are discussed, revealing differences between HCM in younger patient populations and that in older patient populations and its implications for anesthetic management.

A 63-year-old woman was admitted to our hospital due to a grade III systolic murmur over the pulmonary area. A chest x-ray ([Figure 1A][1]) showed cardiomegaly with abnormal vascular shadow over the left atrium area. Transthoracic echocardiography showed coronary artery drainage into pulmonary

We investigated which physical parameter has the greatest impact on the perceived loudness of a systolic murmur in aortic stenosis. Loudness of murmur in aortic stenosis correlated best with peak momentum transfer--and thus with body size--so that loud murmurs predict severe disease less reliably in larger patients.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 24-year-old woman who had moved to the United States 5 years earlier received a routine evaluation. Mild systemic hypertension, a systolic murmur, prominent neck pulsations, and diminished lower-extremity pulses were

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 33-year-old woman was referred to a cardiologist for an early systolic ejection click and grade III/VI mid peaking systolic murmur at the upper left sternal border. An echocardiogram revealed moderate

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 49-year-old woman with exertional chest pain and a systolic murmur at the right upper sternal border radiating to both carotids had a hypercontractile left ventricle (LV) and a 77 mm Hg peak pressure gradient between the LV

[Figure][1] A 24-year-old woman was admitted to the hospital by her general practitioner because of pulselessness in the upper extremities. Except for chronic lower back pain, arthralgia, fatigue, and a loud systolic murmur, clinical symptoms were moderate. The initial echocardiogram

To assess the serial phonocardiographic and echocardiographic change in patients with mitral valve prolapse (MVP), phonocardiograms and echocardiograms were reviewed retrospectively in 116 patients (48 men and 68 women, mean age 27 years) who had been determined to have MVP and were reexamined 4.3 years (range 1 to 14) later by phonocardiography and echocardiography between 1971 and 1988. Follow-up phonocardiograms showed periods when 5 of 18 patients with silent MVP developed mid- or late systolic clicks. Of 57 patients with mid- or late systolic clicks, 15 had silent MVP, 6 developed a late systolic murmur with or without systolic clicks and 1 developed a pansystolic murmur. Two of 9 patients with an isolated late systolic murmur developed a pansystolic murmur. M-mode echocardiograms showed that left atrial and left ventricular dimensions at end-diastole and end-systole increased in patients with systolic murmur (33 +/- 10 vs 35 +/- 11, 46 +/- 6 vs 50 +/- 7 and 29 +/- 4 vs 31 +/- 5 mm, respectively, all p less than 0.001) and no statistically significant changes in any of these dimensions were found in patients without a systolic murmur. The degree of MVP evaluated by the anteroposterior mitral leaflet angle on the 2-dimensional echocardiogram was more severe in patients with a systolic murmur than in patients without systolic murmur (157 +/- 12 vs 131 +/- 16 degrees, p less than 0.001). The degree of prolapse did not change during the follow-up periods. The number of patients with mitral regurgitation detected by pulsed Doppler echocardiography increased from 21 of 72 (29%) to 31 of 72 (43%).(ABSTRACT TRUNCATED AT 250 WORDS)

One in five infants and children at any one time will have a systolic murmur if examined carefully. One in two children will be heard to have a murmur at some stage, particularly in association with a febrile illness. Very few paediatricians in the UK now will recall the days when the finding of such a murmur required a careful evaluation for any history or clinical signs suggestive of rheumatic fever, but all will be aware that about one child in 100 is born with some form of congenital heart disease, many of whom are first diagnosed by the finding of a cardiac murmur. The remainder of the children with murmurs will have no cardiac disease and the murmur will be labelled as innocent or functional. The former term is now the preferred one.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 31-year-old healthy Korean woman was referred for echocardiographic evaluation after a loud systolic murmur was heard over the pulmonic area during a general physical examination. The patient had no

This paper describes a computer analysis and decision system for heart sounds. An ARMA model was applied to identify the characteristics of normal subjects and three groups of patients with mitral stenosis (MS), mitral regurgitation (MR) plus mitral stenosis and uraemia. The information of heart sounds from different groups was selected and pre-treated. Convenient ARMA models of heart sounds were then established. Certain parameters of the ARMA models were identified and it was also found possible to analyse quantitatively different heart sounds (S 1 , S 2 , S 3 , and S 4 ) and diastolic or systolic murmur. o 1. The ARMA spectrum of heart sounds and murmur could be computed with the coefficients of the ARMA model. 2. The main frequency of different heart sounds and murmur could be computed with the characteristic roots (λ) of the auto-regressive equation. 3. The cardiac functional state was described with λ. In particular, when |λ| > | (where λ corresponds to diastolic murmur) heart-failure frequently occurs. By comparison with a vast amount of clinical data, the results have been found to be satisfactory.

A 59-year-old man underwent a quadruple coronary bypass. Nine hours postoperatively, cardiac arrest developed; it was preceded by bradycardia resistant to pacing. Closed-chest massage resulted in a rapid recovery of stable cardiac function followed by the development of cardiogenic shock. A new systolic murmur was appreciated 36 hours following arrest. It was diagnosed at catheterization as a ventricular septal defect that was subsequently found to lie in the posterior ventricular septum, and two operations were necessary to effect closure. The final operation was performed with exposure of the septal defect through the right atrium. Sixteen months after operation, the patient remained well. To our knowledge, this is the first reported instance of a ventricular septal defect occurring secondary to closed-chest massage and also of the closure of a traumatic defect using a right atrial approach.

Separate left ventricular and left atrial myxomas were detected with echocardiography in an asymptomatic young adult with a systolic murmur. Successful surgical removal of both tumors was performed without complications. The value of echocardiography in evaluating heart murmurs of uncertain origin is demonstrated by this unique case.

The assessment of a patient with suspected left ventricular outflow tract (LVOT) obstruction is a common clinical problem. Symptoms such as anginal pain, congestive heart failure, vertigo, or syncope may be due to associated diseases (mainly coronary artery disease), but are often the ominous signs of critical obstruction. Patients are often referred to the cardiologist because of a systolic murmur over the base of the heart. Despite careful physical examination, ECG, and chest x-ray examination, the best means of noninvasive evaluation of these patients is echocardiography. The purpose of this communication is to review the common forms of LVOT obstructions and the role of echocardiography in each specific lesion. Aortic coarctation is not discussed.

The cause of a musical (cooing) murmur produced by a degenerated bioprosthetic valve in the mitral position was investigated. Spectral analysis of the murmur recorded at the chest wall at the site of the maximum palpable impulse showed virtually all sound in a narrow frequency band around the dominant frequency of 158 hertz. The same valve, surgically removed and mounted in the mitral position in a pulse duplicating system, produced an audible musical murmur detected by a phonocatheter in the atrial chamber. Nearly all of the sound-pressure occurred in a narrow band of frequency around 145 hertz. High speed motion pictures (500 frames/s) showed systolic flutter of a flail leaflet. The frequency of this leaflet flutter was 142 hertz. Hot film anemometry showed minimal turbulence, all located near the margin of the regurgitant leaflet. The intensity of the murmur was unrelated to the intensity of turbulence. A second degenerated bioprosthetic valve that produced in vivo a typical blowing holosystolic mitral regurgitant murmur produced in vitro a murmur with a broad range of frequencies (20 to 500 hertz). With this valve, the intensity of the murmur was related to the intensity of the turbulence. Motion pictures showed no leaflet flutter. Flutter of an insufficient valve leaflet causing uniform and periodic high frequency fluctuating pressures therefore appeared to be the cause of the musical quality of the systolic murmur in a degenerated bioprosthetic valve.

A study has been made to determine the value of auscultation and phonocardiography in assessing the result of surgery in cases of pulmonary stenosis with intact ventricular septum and Fallot's tetralogy. In cases of pulmonary or infundibular stenosis with an intact ventricular septum, a successful valvotomy or infundibular resection resulted in marked shortening and softening of the murmur and reduction in the width of splitting of the second sound. Less adequate relief of stenosis caused less shortening of the murmur and less reduction in the splitting. Criteria are given for grading the postoperative severity of the stenosis. In cases of Fallot's tetralogy, a successful valvotomy or infundibular resection (Brock operation) resulted in marked lengthening and intensification of the murmur and, frequently, the emergence of a very soft, audible pulmonary second sound widely separated (average 0.09 second) from the aortic second sound. These changes reflected increased volume rate of pulmonary flow through the stenosis and a rise in pulmonary arterial pressure. Less adequate relief of stenosis caused less prolongation of the murmur and no emergence of a pulmonary second sound. Criteria are given for grading the postoperative result. Auscultation was shown to be an excellent bedside method of predicting the surgical result of a valvotomy in the two conditions, since the change in the length of the murmur and the width of splitting developed rapidly, and accurately reflected the degree to which the stenosis had been relieved. The opposite behavior of the murmur was due to the different dynamic situation in the two conditions. The observations proved that the length of the murmur was directly related to the severity of the stenosis when the ventricular septum was intact, but inversely related in cases of the tetralogy. Following complete valvotomy under direct vision, the right ventricular pressure may fail to drop adequately because of severe subvalvular muscular hypertrophy. The resultant secondary infundibular stenosis may or may not regress over a period of time. The value of serial sound tracings in detecting the trend is emphasized. Gradual shortening of the initially prolonged murmur and narrowing of the split second sound indicate gradual reduction of right ventricular pressure and stenosis. A successful Blalock-Taussig operation for the tetralogy did not lengthen the pulmonary systolic murmur, since the stenosis was not relieved by this operation. This indirectly confirmed the view that the length of the murmur is a function of the degree of stenosis, provided that the systemic resistance remains constant. However, auscultation was of value in other respects. The development of a loud continuous murmur, especially if associated with the emergence of a recordable pulmonary second sound, ensured a good result from this operation. The use of auscultation in evaluating the result of the operation for complete repair of the septal defect and relief of the stenosis in cases of the tetralogy is discussed. The ideal end result is either a short ejection systolic murmur and narrow splitting of the second sound or no murmur at all, with normal heart sounds. The use of amyl-nitrite inhalation and phenylephrine in determining the origin of a residual systolic murmur is discussed.

Clinical and pathologic findings have been reported in two young patients with severe hypertension resulting from coarctation of the abdominal aorta and stenosis of the proximal portions of the renal arteries by intimal proliferation. It appears likely from these cases and from those in the literature that the renal artery lesions are initiated by the high velocity jet produced by the coarctation, and that hypertension of the Goldblatt type may be expected as an ultimate consequence. The presence of forceful arterial pulses and marked hypertension in the lower extremities are previously unrecognized features of the atypical clinical picture which these patients may exhibit. Although a systolic murmur and thrill over the abdomen and back may suggest the diagnosis, as in both cases reported here, visualization of the abdominal aorta and its major branches is necessary for the planning of appropriate surgical intervention.

Summary The pattern of a systolic murmur is closely related to the hemodynamic alterations in the cardiovascular system. Close attention to the pattern (timing and shape) of a murmur is necessary for the proper understanding of a cardiac disorder from a functional point of view. Similarly the pattern of a systolic murmur is probably the single most useful feature available for distinguishing an organic from an “innocent” murmur. The more commonly used terms of description of murmurs, that is, according to intensity, location, quality and transmission are most useful when considered within the framework of murmur pattern. Whereas the ability to describe accurately a murmur according to its intensity, location, quality, and transmission is acquired with moderate ease, to learn to recognize the pattern of a murmur by auscultation requires more intense application on the part of the observer. Frequent correlation of auscultatory findings with the phonocardiogram improves one's ability to recognize the timing and shape of a murmur. With increasing ability reference to the phonocardiogram becomes less necessary. Two types of innocent systolic murmurs which occur frequently are the circumscribed (or late) systolic murmur believed to be of extracardiac origin and the ejection systolic murmur conveniently referred to as Still's murmur. Correct identification of the first and differentiation from the murmur of mitral regurgitation are possible by its nonholosystolic nature and sometimes by the association of systolic click(s) in the same or other areas of the precordium. Correct identification of Still's murmur and differentiation from the murmur of aortic stenosis is usually possible by its characteristic quality and its variability, as described earlier. Obviously a murmur is only one of the clinical signs available to the clinician and concentration on this one sign to the exclusion of the other available information is unrewarding and even misleading. Only with proper attention to the history, to all of the physical abnormalities (or the lack of same), and to the available laboratory investigations will an intelligent evaluation of a systolic murmur be forthcoming.

This echocardiographic study has demonstrated that the finding of systolic separation of the mitral leaflets is not specific for those patients with the late systolic clicklate systolic murmur syndrome but is also seen with ruptured chordae tendineae and in cardiomyopathy patients with mitral regurgitation. From these observations and with the help of observations of others, we have reasoned that the mitral regurgitation associated with cardiomyopathy is not due to mitral annulus dilatation but to papillary muscle dysfunction.

A clinical and pathologic account is given of the case of an African patient with syphilitic aortic incompetence who also had a loud mitral systolic murmur. This murmur proved to be due to a large aneurysm of the anterior cusp of the mitral valve, through the openings of which blood could pass from the left ventricle to the left atrium. Most of the cases reported have been due to bacterial endocarditis. The etiology of the case described here is uncertain. There was no postmortem evidence of bacterial endocarditis.

Ten infants under 6 months of age in congestive heart failure have been studied and were proved to have only a large patent ductus arteriosus. Auscultation and phonocardiography of the chest wall showed only a systolic murmur along the left sternal border. Intracardiac phonocardiography revealed a continuous murmur inside the pulmonary artery in 9 out of the 10 cases. The role of intracardiac phonocardiography in the diagnosis of large patent ductus arteriosus in early infancy is emphasized.

Unusual auscultatory and palpatory findings are described in a case of acute destruction of the mitral valve by staphylococcal endocarditis. An early decrescendo systolic murmur ending well before aortic closure was heard and recorded at the apex. The apical impulse consisted of grossly exaggerated a and rapid filling waves, and a nonsustained outward systolic movement of normal height. These findings are discussed in the light of hemodynamic data obtained. The importance of careful analysis of such physical signs is stressed.

The clinical and operative findings in a 50 year old patient with a huge thymic cyst are presented. Pericardial effusion with tamponade occurred in association with the cyst, and tussive syncope and a reversible systolic murmur over the outflow tract were noted. Removal of the cyst corrected the murmur and electrocardiographic abnormalities and relieved all symptoms.

1. 1. Forty-four proved cases of ventricular septal defect have been reviewed from the auscultatory and phonocardiographic stand-point. 2. 2. A loud, harsh pansystolic murmur, moderately split and normal to increased intensity of pulmonary closure, a third heart sound at the apex and occasionally a mid-diastolic ventricular filling murmur are the most characteristic observations. The systolic murmur is invariably associated with a thrill and is maximal in the third or fourth left intercostal space. 3. 3. An aortic diastolic murmur was observed in three patients who had aortic insufficiency. 4. 4. A widely split and decreased sound of pulmonary closure was noted in four patients with associated infundibular pulmonary stenosis. 5. 5. Pulmonary hypertension caused a narrowly split or single second sound that was of increased intensity. The systolic murmur was softer and non-holosystolic in three of seven patients with pulmonary hypertension. 6. 6. The differentiation between ventricular septal defect and other conditions associated with a similar harsh systolic murmur was briefly discussed.

Summary Eight cases of ventricular septal perforations are presented, and the present literature, consisting of 132 cases, is reviewed. The diagnosis of this condition should be strongly considered when a patient with an acute myocardial infarction suddenly develops a blowing systolic murmur along the lower left sternal border. Recognition is of importance in a consideration of the prognosis, as less than 10 per cent survive one year. In one patient, cardiac catheterization was performed in an attempt to confirm the diagnosis, and in two patients the unusual combination of a ruptured septum and a ruptured ventricle was present. The differential diagnosis has been discussed, with particular attention to the differentiation of septal perforation from papillary muscle rupture.

1.1. A review has been made of instances of ruptured papillary muscle of the heart. 2.2. Another case is added with a different etiology, that of periarteritis with necrosis of the muscle. 3.3. Tentative criteria based upon deductions from the data in thirty-seven cases are suggested for the antemortem diagnosis of ruptured papillary muscle. 4.4. "In a patient with cardiac infarction who suddenly collapses and in whom a loud systolic murmur develops at the apex without a thrill, if you think of and diagnose a ruptured papillary muscle, you will sometimes be right". (Wood)

1. 1. A systolic, ejection type of bruit is sometimes heard in the medial supraclavicular regions of healthy young persons. 2. 2. This bruit, when prominent, may transmit to the basal region of the heart and either simulate a systolic murmur or augment one already present. 3. 3. At times, the systolic murmur so produced may be Grade 3 in intensity and simulate an organic murmur. 4. 4. Persons who exhibit this phenomenon are often of slender body build and have ventricular rapid filling sounds, vigorous apical impulse, and venous hum.

Eighty-two healthy premature infants, 2 of whom weighed more than 2,000 grams were examined serially during their first 18 months of life. Eighty per cent had a systolic murmur, most often at the lower left sternal border or inside the apex, at some time during this period of observation. The incidence increased after the first month of life and appeared to be greater in infants with a hemoglobin concentration below 9 Gm. Four per cent had congenital heart disease; this is higher than the reported incidence in full-term infants.