Full text


(Submitted December 3, 1965; revision accepted for publication July 1, 1966.)

Supported in part by a grant-in-aid from the Kansas Heart Association. This work was completed while CV. was a Cardiovascular Trainee of the National Institute of Health at the University of Kansas Medical Center (Grant


1 Ti HE-5670).

ADDRESS for reprints: (A.M.D.) as above, Rainbow Boulevard at 39th Street, Kansas City, Kansas 66103.

Pmuxrmcs, Vol. 38, No. 5, November 1966













Choompol Vongprateep, M.D., Ronald M. Lauer, M.D.,

and Antoni M. Diehl, M.D.

From the Department of Pediatrics, University of Kansas School of Medicine, Katuas City, Kansas


HE esophageal site as an area for

car-diac auscultation has been used for

many years.’8 In 1962 Rodgers described a

crystal microphone transducer for intraeso-phageal phonocardiography which proved to be useful in the evaluation of murmurs occurring in the left atrium and great

vessels.9 This latter report prompted us to

study the intraesophageal area for the de-tection of rheumatic disease affecting the mitral valve.


Twenty-nine patients with either acute rheumatic fever or a known history of rheu-matic fever and 16 normal controls were studied at the Children’s Cardiac Center,

Kansas City, Missouri, and the University of Kansas Medical Center, Kansas City,

Kansas. The age range was 6 to 27 years.

After thorough explanation of the

proce-dure the patient was placed in a

comfort-able recumbent position. A Model 191 AEL#{176} phonocatheter was introduced via the nares into the esophagus during the act of swallowing. The tip of the catheter was positioned to the level of the left atrium

with the aid of an image intensifier. The catheter was then adjusted to a point where

heart sounds and murmurs were best

re-corded as judged by auscultation and

view-ing of the oscilloscopic tracing. A schematic

diagram of the method is shown in Figure

0 American Electronic Labs, Inc., Lansdale,


Fic. 1. Diagram of the method and instrumentation for recording intraesophageal phonocardiograms.

Note the proximity of the tip of the catheter to

the left atrium.

1. The signal from the sound pickup was fed into a Model 191 AEL preamplifier and then into a two channel Sanborn

galvano-metric oscillograph. All photographic

trac-ings were recorded with a paper speed of

75 mm/sec with carotid artery tracing,

jug-ular venous tracing, apex cardiogram, and

electrocardiogram used as reference.

Imme-diately following the intraesophageal

re-cording a surface phonocardiogram was

oh-tamed from the aortic area, pulmonary area, lower left sternal margin, and apex.


Of the 16 patients in the control group,

10 had nonsignificant systolic ejection mur-murs, 2 had vibratory nonsignificant systol-ic murmurs, and 4 had no murmur on sun-face auscultation. In no instance was a

murmur recorded by the intraesophageal



4 I


geal phonocardiograms in the two patients

with vibratory, nonsignificant systolic

mur-murs at the lower left sternal border were

identical with the surface phonocardi-ograms as shown in Figure 2B. Note that

the murmur is short, of low frequency, and

does not occupy the whole of systole. In the 10 patients with nonsignificant systolic

murmurs on surface auscultation, the

in-traesophageal phonocardiogram recorded

the diamond shaped murmur with similar

morphology to the surface

phonocardi-ogram as shown in Figure 2C. This type of

murmur is short, starts after the first heart



L_sal SM 2 SM 3M 2 #{149}IM 2

., , #,




PA 1SM 2 SM2 SM2




X4 J4Tz I


FIG. 2. Surface and intraesophageal

phonocardio-grams. 1 = first heart sound. 2 = second heart

sound. 3 = third heart sound. 4 = fourth heart

sound. SM = systolic murmur. DM = diastolic

murmur. EKG = electrocardiogram. CT = carotid

tracing. ACG = apex cardiogram. LSB = lower

left sternal border. Log: logarithmic sound filter used. A. Thirteen-year-old girl who had no heart disease or history of rheumatic fever. These control records show no murmur. B. Six-year-old boy who had no heart disease or history of rheumatic fever. Grade II low-pitched, vibratory nonsignificant mar-mum was heard at the left lower sternal border. The murmur recorded by intraesophageal technique does not show a pansystolic murmur. C.

Ten-year-old girl with Grade II nonsignificant systolic

ejec-tion murmur at the pulmonic area. There was no

evidence of heart disease or history of rheumatic fever. D. Eleven-year-old boy with acute rheu-matic fever and minimal mitral regurgitation. The

intraesophageal recording delineates the

pan-systolic murmur more clearly than the surface







ApE,I 2

I 1’ i’

_1 n_J IS. 1SM I$M2 C LOG LOG %_*l_. ! $EI,I1SNdSM

Fic. 3. Surface and intraesophageal phonocardio-grams. See Figure 2 for key. A. Eighteen-year-old girl with minimal mitral regurgitation. A Grade Il/VI pansystolic murmur was heard at the apex with transmission to the left axilla. The intra-esophageal phonocardiogram records the

regurgi-tant murmur with better definition than the

sum-face study. B. Fourteen-year-old boy with quiescent

rheumatic fever in whom a pansystolic murmur is

recorded on the intraesophageal phonocardiogram but not on the surface phonocardiogram. C. Six-year-old boy with acute rheumatic fever. A pan-systolic murmur is recorded by the intraesophageal technique but not on surface phonocardiography. D. Twelve-year-old girl with acute rheumatic fever in whom the intraesophageal phonocardiogram me-corded a loud pansystolic murmur whereas the surface study failed to detect this organic murmur.

sound, and ends before the second heart sound.

Of the 29 patients with either acute

nheu-matic fever or a known history of rheumatic fever, clinical signs of mitral regurgitation

were present in eleven, aortic regurgitation in three and no murmur was heard in the remaining


In all 11 patients with

cmi-cal signs of mitral regurgitation on surface auscultation, the surface phonocardiogram recorded the pansystolic murmur. Of stnik-ing importance is the significantly more dis-tinct recording of this murmur in all

pa-tients on the intraesophageal







. DM. I






FIG. 4. Surface and intraesophageal phonocardiograms. See Figure 2 for key. A. Ten-year-old girl with acute rheumatic fever. Although a nondiagnostic systolic murmur is recorded on the surface apex

phono-cardiogram, the intraesophageal study shows a prominent pansystolic murmur. B. Thirteen-year-old boy with rheumatic pcricardial effusion. A low frequency systolic murmur at the apex is recorded with surface phonocardiogaphy. A holosystolic murmur is well recorded on the intraesophageal tracing, as is a

mid-diastolic low frequency murmur.


SM 2





However, in none of three patients with clinical auscultatory findings of mild aortic regurgitation was it possible to record the high-pitched, decrescendo, diastolic mur-mur on the surface or intraesophageal pho-nocardiogram.

In none of the 15 patients with no

inur-mur on clinical auscultation was a murmur

recorded on surface phonocardiography.

However, in


of these 15 patients the

in-traesophageal phonocardiogram demon-strated murmurs which were not discern-ible by clinical auscultation or surface pho-nocardiogram. Brief clinical histories of these patients follow.



A 14-year-old boy had acute rheumatic fever in 1954 with polyarthritis, carditis, and mitral regurgitation. Auscultatory findings in 1964

re-vealed a normal first heart sound and the second heart sound was normally split and normally

accentuated. There was a Grade 1/VI short,

ejection type, systolic murmur localized at the apex. No diastolic murmur was heard. The sur-face phonocardiogram taken at the apex did not

record a significant heart murmur. A definite

pan-systolic murmur consistent with mitral

regurgita-tion was heard and recorded on the intraesophageal

phonocardiogram as shown in Figure 3B.



A 6-year-old boy was admitted with acute

rheumatic fever manifested by polyarthritis,

radio-graphic evidence of cardiomegaly, elevated ASO

titer, sedimentation rate, and muco-protein and a

positive C-reactive protein. The second heart

sound on auscultation was normal. A normal, third heart sound was heard at the left lower sternal border. There was a Grade 1/VI short systolic

murmur at the apex and left sternal border, this

murmur beginning with the first heart sound and

having late systolic attenuation. No diastolic

mum-mur was heard. Although the surface

phono-cardiogram did not record a significant heart

murnrnr, the intraesophageal phonocardiogram

de-lineated a pansystolic murmur which was consist-ent with mitral regurgitation as demonstrated in Figure 3C.



A 12-year-old girl was admitted with acute rheumatic fever characterized by polvarthritis; carditis, elevated ASO titer, and abnormal sedimen-tation rate, muco-protein and C-reactive protein. On auscultation the first heart sound was normal and the second sound was normally split and

accentuated. A Grade 1/VI systolic murmur with late systolic attenuation was heard at the apex and lower sternal border; this murmur was not transmitted to the left axilla, was not characteristic of mitral regurgitation, and could not be



through the intraesophageal phonocatheter a loud pansystolic murmur was heard and recorded (Fig-ure 3D). Two days later a transient, Grade Il/VI, blowing, pansystolic murmur consistent with mitral regurgitation was heard at the apex on surface auscultation.

Case 4

A 10-year-old girl was admitted with acute

rheumatic fever with manifestations of aortic

me-gurgitation, polyarthralgia, increased ASO titer and abnormal acute phase reactants. Auscultation

revealed a normal first heart sound, a normally

split second heart sound which was normally

accentuated and a Grade Il/VI, high-pitched, decrescendo, diastolic murmur at the left sternal border and aortic area consistent with aortic re-gurgitation. A Grade 1/VI, short, ejection-type,

systolic murmur was also heard at the apex and

lower left sternal border. No characteristic mitral regurgitation murmur was recorded on the surface phonocardiogram. The intraesophageal

phonocar-diogmam displayed a loud pansystolic murmur of

mitral regurgitation (Figure 4A). A left ventricular

angiocardiogram confirmed the presence of a

moderate degree of mitral regurgitation in this


Case 5

A 13-year-old boy had rheumatic fever with the

manifestations of pericarditis, pericardial effusion, polyarthralgia, erythema marginatum, elevated ASO titer, and abnormal acute phase reactants.

On auscultation the heart tones were of poor

quality, the second heart sound physiologically

split, and a third heart sound could be heard

faintly. No heart murmur was heard on admission. Several days later a Grade 1/VI, short, high-pitched, decrescendo, diastolic murmur was heard at the aortic area and at the second and third left interspaces. The surface phonocardiogram

recorded only a low frequency, nonsignificant

systolic murmur at the apex (Figure 4B). The

intraesophageal phonocardiogram recorded a defi-nite pansystolic murmur and a low frequency, mid-diastolic murmur which are consistent with mitral valvulitis.


The esophageal proximity to the left atni-um allows displacement forces generated

within the left atrium to be transmitted to

the retrocardiac area. The intraesophageal microphone used in this study is insensitive to air-conducted sound, but it responds to

pressure displacement in a fluid medium.

Thus the placement of this type of catheter

in the intraesophageal retrocardiac area is optimal for the recording of the turbulence

of mitral regurgitation.

Intraesophageal phonocardiography is particularly helpful when used in patients suspected of having rheumatic heart

dis-ease but in whom characteristic murmurs of

mitral valve involvement cannot be clearly

detected by clinical auscultation or surface

phonocardiography. Also, when the chest

wall is unduly thick or when a pericardial

effusion prevents the transmission of heart sounds and murmurs to the surface, the in-traesophageal phonocardiogram may record

a characteristic murmur of mitral valve



Twenty-nine rheumatic subjects and 16 normal individuals have been studied by intraesophageal phonocardiography. In the normal group no unusual sounds or

mur-murs were discovered by this technique.

However, in rheumatic patients with clini-cal mitral regurgitation the esophageal pho-nocardiogram more clearly recorded the murmur than the surface phonocardiogram. In five patients murmurs of mitral disease were recorded by the intraesophageal tech-nique that were not discernible by clinical examination or surface phonocardiography. Intraesophageal phonocardiography is par-ticularly valuable in clinical situations wherein rheumatic heart disease is suspect-ed and the typical clinical findings of mitral regurgitation are absent or equivocal.


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a new departure in physical diagnosis.

Lan-cet, 2:1037, 1892.

3. Benjamins, C. E. : L’auscultation et L’enregis-trement des bruits du couer par voie esopha-gienne. J. Physiol. Path. Gen., 16:597, 1914. 4. Benjamins, C. E.: Uber die Untersuchung der

Hersens von der Speiserohre aus Das Oesopha-gogram, die Registrierung der osophagealu Herztone. Piluger’s Arch. Ges. Physiol., 158:

125, 1914.


Asino-ronismo ventriculas per seccion de las ramas del las de His. I. Seccion dela mama derecha. Rev. Soc. Arg. Biol., 12:331, 1936. 6. Lian, C. : L’auscultation cardio-oesophagienne.

Arch. Mal. Coeur, 38:221, 1945.

7. McKusick, V. A.: Cardiovascular Sound in

Health and Disease. Baltimore: The Williams

and Wilkins Company, p. 83, 1958. 8. Rumbaugh, I. F., Goodwin, R. S., Leighton,

R. F., Ryan, J. M., and Wooley, C. F.:

Intraesophageal phonocardiography and the indirect left atrial pulse. In Segal, B. L., ed.: The Theory and Practice of Auscultation.

Philadelphia: F. A. Davis Co., pp. 55-534, 1964.




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