The Role of Auscultation in the Differentiation of Fallot's Tetralogy from Severe Pulmonary Stenosis with Intact Ventricular Septum and Right-to-Left Interatrial Shunt

Abstract

A clinical and phonocardiographic study has been made of the murmurs and heart sounds in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact septum and right-toleft interatrial shunt. A striking difference in the behaviour of the systolic mnurlmur was found in the two conditions and this affords a new, simple bedside method of diagnosis. Important differences in the behaviour of the heart sounds were also found, but these are usually more difficult to evaluate clinically and may require special study.

Auscultatory and Phonocardiographic Signs of Pulmonary Stenosis

“…This was also found by Vogelpoel and Schrire (1955) whose clear recordings showed a pulmonary component in only 3 (heard in one) of their 18 cases of Fallot's tetralogy. In our cases, the average pulmonary artery flow was 2 7 litres a minute in the Fallot group compared with 5 4 litres in pure pulmonary stenosis, confirming the findings of Soulie et al (195la).…”

“…after aortic closure) in one of our cases after a Blalock's operation, and in two others after valvotomy (delay 0*05 and 0-12 sec.). It follows that the presence of the pulmonary component of the second sound (recorded or heard) in rare cases of Fallot's tetralogy 314 PHYSICAL SIGNS OF PULMONARY STENOSIS should indicate a greater pulmonary flow than usual and this has been shown in one case by Vogelpoel and Schrire (1955). Similarly the absence of the pulmonary component in a few cases of severe pure pulmonary stenosis was always associated with an unusually small pulmonary flow.…”

“…12). This probably accounts for the fact that in severe cases with a short murmur the diagnosis always proved to be Fallot's tetralogy, as stated by Vogelpoel and Schrire (1955). Conversely a murmur sufficiently long to extend past aortic closure was always associated with a closed ventricular septum.…”

“…Dilatation of the pulmonary artery is associated with a pulmonary early systolic ejection sound in mild cases. The obstruction to right ventricular discharge prolongs right ventricular systole resulting in late closure of the pulmonary valve (Leatham, 1951(Leatham, , 1952Borges et al, 1952;Kjellberg et al, 1955;Vogelpoel and Schrire, 1955) and produces an ejection type of systolic murmur (Leatham, 1955).…”

The Clinical Value of Angiocardiography

“…Although the diagnosis can now be made on clinical evidence with confidence (36,37), the two conditions cannot always be differentiated with certainty, so that one often has to resort to angiocardiography in order to establish the exact anatomical abnormality.…”