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Corresponding author: Dr Ivan Stankovic, Department of Cardiology, University Clinical Hospital Centre Zemun, Vukova 9, 11070 Belgrade, Serbia. Tel.: +381-11-316-88-78; fax: +381-11-316-88-78.
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 1A 12-lead electrocardiogram showing biphasic T-waves in leads V3-V6 consistent with Wellens syndrome.
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.
