Canadian Journal of Cardiology

An Echocardiographic Illustration of the Dock's Murmur in a Patient With Wellens Syndrome

Published:December 29, 2015DOI:
      A 42-year-old man complained of a recurring substernal chest pain that was initially thought to be related to hiatus hernia and reflux disease. The 12-lead electrocardiogram revealed biphasic T-waves in leads V3-V6, consistent with Wellens syndrome (Fig. 1). A mild early diastolic heart murmur resembling aortic regurgitation could be heard on auscultation, although neither an aortic regurgitation nor regional wall motion abnormalities were detected during standard echocardiographic examination. However, the colour-coded 2-dimensional imaging of proximal and distal portions of the left anterior descending coronary artery (LAD) at rest as well as transthoracic Doppler echocardiography of LAD flow provided the explanation for the murmur (Fig. 2). The interrogation of the proximal LAD (Fig. 2, left panel) revealed the turbulent flow as evident from the mosaic pattern of colours and high flow velocity suggestive of stenotic flow acceleration. The interrogation of the distal portion of the LAD (Fig. 2, right panel) showed a normal flow pattern (a homogeneously coloured red jet) and a normal coronary flow velocity. Coronary angiography (Fig. 2, central panel) showed a critical narrowing of the proximal LAD, which was treated with stent placement (colonic folds are also visible in the bottom of Fig. 2, because of barium swallow radiography performed 2 days before angiography).
      Figure thumbnail gr1
      Figure 1A 12-lead electrocardiogram showing biphasic T-waves in leads V3-V6 consistent with Wellens syndrome.
      Figure thumbnail gr2
      Figure 2Left anterior descending coronary artery (LAD) flow imaging in a patient with the Dock's murmur. Left panel: a turbulent flow by colour-coded imaging (top) is associated with a very high coronary flow velocity in Doppler echocardiography (bottom); centre panel: coronary angiography showing a critical proximal LAD stenosis (a dashed white circle) and normal luminal diameter of distal LAD (a dashed black circle); right panel: normal coronary flow pattern and velocity of the distal LAD.
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        • Dock W.
        • Zoneraich S.
        A diastolic murmur arising in a stenosed coronary artery.
        Am J Med. 1967; 42: 617-619