[Proceedings: The specific ECG of the mesosystolic click-telesystolic murmur syndrome (So-called subvalvular mitral insufficiency). Zäziwil study. III].

For the diagnosis of small ischemic areas of the posterior wall of the heart, and particularly in the papillary muscles of the left ventricle, the 12 standard leads of the ECG are insufficient. The leads of Nehb and especially the new unipolar lead a VH (of the dorsal Nehb point D but with switch scheme of Goldberger) will be found more helpful. In all 33 patients with the clinical findings of midsystolic click--late systolic murmur syndrome a negative T in lead aVH was found; only 9 patients also showed ischemic signs in lead D of Nehb and only 6 patients in standard leads as well. These findings suggest that the midsystolic click--late systolic murmur syndrome is always caused by a papillary muscle lesion, even in young patients. A negative T in lead aVH (isolated or combined with signs of ischemic alterations on other leads) appears to point to the existence of a papillary muscle defect, even with a normal auscultatory finding. In this case the lesion will be too small to cause papillary muscle dysfunction. Usually, however, the typical auscultatory finding will be subvalvular mitral insufficiency (i.e. midsystolic click--late systolic murmur or a murmur called "pa-futt" by Huchard, in our opinion the same finding). In view of the fact that papillary muscles are vascularized by the finest ends of the coronary arteries, it seems obvious that a negative T in lead aVH could also signify the beginning of coronary heart disease.