On the Mechanism of the Austin Flint Murmur

We studied mitral valve motion in 15 patients with aortic regurgitation and an Austin Flint murmur by recording simultaneously the phonocardiogram, apexcardiogram, and mitral valve echocardiogram. In 14 patients the murmur was presystolic, and in 13 of these a middiastolic component was present as well. The middiastolic component occurred after the period of rapid ventricular filling as the mitral valve was closing. The presystolic component occurred either as the mitral valve was rapidly closing following normal atrial opening movement or during the entire period of atrial systole. In this latter situation the valve did not open completely with atrial systole. All of these patients demonstrated a prominent A wave on the apexcardiogram. In patients with a two-component Flint murmur, isometric handgrip exercise greatly accentuated the murmur, altered the pattern of valve motion so that atrial systole was no longer effective in opening the valve, and reduced the size of the apex A wave. One patient had only a middiastolic Flint murmur. The mitral valve was open for only a brief period in middiastole and did not reopen with atrial systole. Cardiac catheterization documented elevation of ventricular diastolic pressures above left atrial pressures during most of diastole. Amyl nitrite reduced diastolic ventricular pressure and permitted the mitral valve to open with atrial systole. The apex A wave, which was small at rest, increased in size after amyl nitrite. Our findings suggest that the Flint murmur is due to antegrade flow across the mitral valve. The rumble occurs during rapid closure of the valve as flow velocity is increasing although actual volume of flow may be decreasing.