Number 08-04: Where is the murmur from?
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Case from: Marshall W. Winner III, Subha V. Raman. The Ohio State University, Columbus, Ohio, USA.
Clinical history: A 20 year-old Hispanic male with a murmur since childhood presented with worsening exertional chest pressure and dyspnea. CMR was ordered for further evaluation.
1. Magnitude and velocity encoded images (top L and R) demonstrate a large patent ductus arteriosus with continuous flow. In the flow map (top right), flow towards the head is white, towards the feet black. Pulmonary flow (white) has a black continuous retrograde jet from the aorta. This is the pda flow, and together with the moderate AR, is severe enough to cause diastolic flow reversal in the aorta (the aorta turning white in diastole). The flow maps can be used to calculate Qp:Qs which was 1:2.
2. A sub-aortic membrane resulting in turbulent flow across the LVOT with a peak velocity of 3.1 m/s and moderate aortic insufficiency. The still frame images were acquired using 3D free-breathing SSFP navigator sequence (bottom right) and Flash cine still (bottom left) show the membrane.
CMR accurately and non-invasively quantified multiple abnormalities in a patient with previously undiagnosed congenital heart disease.