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Transposition of the great arteries, right aortic arch, coarctation, and isolation of the left subclavian artery: Report of surgical therapy

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PII: 0002-8703(81)90205-2 352 Brief communications ruptured chordae tendineae. Pathologic examination revealed scarring and myxomatous degeneration of the mitral valve. The origin of the systolic murmur, mimicking that of aortic stenosis, is well documented to be due to a regurgi- tant jet striking the anterosuperior wall of the left atrium adjacent to the aorta, thus producing radiation toward the carotid arteriessm5 However, the cause of the diastohe murmur, mimicking aortic regurgitation, is not so well defined. Pulmonic insufficiency is made unlikely by the location of the murmur in the aortic region and by its timing, beginning before the pulmonic closure sound. Mitral flow murmurs tend to be rumbling and mid- diastolic, while the murmur in this case was high-pitched and early diastolic. Given the timing of the diastolic murmur, coincident with the continued early diastohc mitral prolapse, we believe the murmur was due to turbulence created by the flail leaflet describing a rapid movement from its prolapsed position in the left atrium to the open position in the left ventricle, in the face of the onrush of blood from a volume-overloaded left atrium in early diastole. REFERENCES Perloff JK, Harvey WP: Auscultatory and phonocardio- graphic manifestations of pure mitral regurgitation. Progr Cardiovasc Dis 5:172, 1962. Cohen LS: Atypical and acute mitral regurgitation. In Leon DF, Shaver JA, editors: Physiologic principles of heart sounds and murmurs. American Heart Association Mono- graph No. 46. New York, 1975, American Heart Association, pp 122-125. Edwards JE, Burchell HB: Endocardial and intimal lesions Get impact) as possible sites of origin of murmurs. Circula- tion I&946, 1958. Bureh GE, Phihips JH: Murmurs of aortic stenosis and mitral insufficiency masquerading as each other. AM HEART J 66:439, 1963. Antman EM, Angoff GH, Sloss LJ: Demonstration of the mechanism by which mitral regurgitation mimics aortic stenosis. Am J Cardiol 42:1044,

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