For potential or actual medical emergencies, immediately call 911 or your local emergency service. Right atrial enlargement (hypertrophy) leads to stronger electrical currents and thus enhancement of the contribution of the right atrium to the P-wave. Novel Electrocardiographic Patterns for the Prediction of Hypertensive Disorders of Pregnancy--From Pathophysiology to Practical Implications. Clinical electrocardiography and ECG interpretation, Cardiac electrophysiology: action potential, automaticity and vectors, The ECG leads: electrodes, limb leads, chest (precordial) leads, 12-Lead ECG (EKG), The Cabrera format of the 12-lead ECG & lead aVR instead of aVR, ECG interpretation: Characteristics of the normal ECG (P-wave, QRS complex, ST segment, T-wave), How to interpret the ECG / EKG: A systematic approach, Mechanisms of cardiac arrhythmias: from automaticity to re-entry (reentry), Aberrant ventricular conduction (aberrancy, aberration), Premature ventricular contractions (premature ventricular complex, premature ventricular beats), Premature atrial contraction(premature atrial beat / complex): ECG & clinical implications, Sinus rhythm: physiology, ECG criteria & clinical implications, Sinus arrhythmia (respiratory sinus arrhythmia), Sinus bradycardia: definitions, ECG, causes and management, Chronotropic incompetence (inability to increase heart rate), Sinoatrial arrest & sinoatrial pause (sinus pause / arrest), Sinoatrial block (SA block): ECG criteria, causes and clinical features, Sinus node dysfunction (SND) and sick sinus syndrome (SSS), Sinus tachycardia & Inappropriate sinus tachycardia, Atrial fibrillation: ECG, classification, causes, risk factors & management, Atrial flutter: classification, causes, ECG diagnosis & management, Ectopic atrial rhythm (EAT), atrial tachycardia (AT) & multifocal atrial tachycardia (MAT), Atrioventricular nodal reentry tachycardia (AVNRT): ECG features & management, Pre-excitation, Atrioventricular Reentrant (Reentry) Tachycardia (AVRT), Wolff-Parkinson-White (WPW) syndrome, Junctional rhythm (escape rhythm) and junctional tachycardia, Ventricular rhythm and accelerated ventricular rhythm (idioventricular rhythm), Ventricular tachycardia (VT): ECG criteria, causes, classification, treatment, Long QT (QTc) interval, long QT syndrome (LQTS) & torsades de pointes, Ventricular fibrillation, pulseless electrical activity and sudden cardiac arrest, Pacemaker mediated tachycardia (PMT): ECG and management, Diagnosis and management of narrow and wide complex tachycardia, Introduction to Coronary Artery Disease (Ischemic Heart Disease) & Use of ECG, Classification of Acute Coronary Syndromes (ACS) & Acute Myocardial Infarction (AMI), Clinical application of ECG in chest pain & acute myocardial infarction, Diagnostic Criteria for Acute Myocardial Infarction: Cardiac troponins, ECG & Symptoms, Myocardial Ischemia & infarction: Reactions, ECG Changes & Symptoms, The left ventricle in myocardial ischemia and infarction, Factors that modify the natural course in acute myocardial infarction (AMI), ECG in myocardial ischemia: ischemic changes in the ST segment & T-wave, ST segment depression in myocardial ischemia and differential diagnoses, ST segment elevation in acute myocardial ischemia and differential diagnoses, ST elevation myocardial infarction (STEMI) without ST elevations on 12-lead ECG, T-waves in ischemia: hyperacute, inverted (negative), Wellen's sign & de Winter's sign, ECG signs of myocardial infarction: pathological Q-waves & pathological R-waves, Other ECG changes in ischemia and infarction, Supraventricular and intraventricular conduction defects in myocardial ischemia and infarction, ECG localization of myocardial infarction / ischemia and coronary artery occlusion (culprit), The ECG in assessment of myocardial reperfusion, Approach to patients with chest pain: differential diagnoses, management & ECG, Stable Coronary Artery Disease (Angina Pectoris): Diagnosis, Evaluation, Management, NSTEMI (Non ST Elevation Myocardial Infarction) & Unstable Angina: Diagnosis, Criteria, ECG, Management, STEMI (ST Elevation Myocardial Infarction): diagnosis, criteria, ECG & management, First-degree AV block (AV block I, AV block 1), Second-degree AV block: Mobitz type 1 (Wenckebach) & Mobitz type 2 block, Third-degree AV block (3rd degree AV block, AV block 3, AV block III), Management and treatment of AV block (atrioventricular blocks), Intraventricular conduction delay: bundle branch blocks & fascicular blocks, Right bundle branch block (RBBB): ECG, criteria, definitions, causes & treatment, Left bundle branch block (LBBB): ECG criteria, causes, management, Left bundle branch block (LBBB) in acute myocardial infarction: the Sgarbossa criteria, Fascicular block (hemiblock): left anterior & left posterior fascicular block on ECG, Nonspecific intraventricular conduction delay (defect), Atrial and ventricular enlargement: hypertrophy and dilatation on ECG, ECG in left ventricular hypertrophy (LVH): criteria and implications, Right ventricular hypertrophy (RVH): ECG criteria & clinical characteristics, Biventricular hypertrophy ECG and clinical characteristics, Left atrial enlargement (P mitrale) & right atrial enlargement (P pulmonale) on ECG, Digoxin - ECG changes, arrhythmias, conduction defects & treatment, ECG changes caused by antiarrhythmic drugs, beta blockers & calcium channel blockers, ECG changes due to electrolyte imbalance (disorder), ECG J wave syndromes: hypothermia, early repolarization, hypercalcemia & Brugada syndrome, Brugada syndrome: ECG, clinical features and management, Early repolarization pattern on ECG (early repolarization syndrome), Takotsubo cardiomyopathy (broken heart syndrome, stress induced cardiomyopathy), Pericarditis, myocarditis & perimyocarditis: ECG, criteria & treatment, Eletrical alternans: the ECG in pericardial effusion & cardiac tamponade, Exercise stress test (treadmill test, exercise ECG): Introduction, Indications, Contraindications, and Preparations for Exercise Stress Testing (exercise ECG), Exercise stress test (exercise ECG): protocols, evaluation & termination, Exercise stress testing in special patient populations, Exercise physiology: from normal response to myocardial ischemia & chest pain, Evaluation of exercise stress test: ECG, symptoms, blood pressure, heart rate, performance, P pulmonale: right atrial enlargement (hypertrophy, dilatation), P mitrale: left atrial enlargement (hypertrophy, dilatation), P mitrale: leftatrial enlargement (hypertrophy, dilatation). Tests may be done to check blood sugar, cholesterol levels, and . Such a P-wave is calledP pulmonalebecause pulmonary disease is the most common cause (Figure1). Connect with a U.S. board-certified doctor by text or video anytime, anywhere. Related article: Bays syndrome and interatrial blocks. [7] However, if atrial fibrillation is present, a P wave would not be present. Therefore, the criteria for diagnosing LAE on a 12-lead ECG is as follows: P-mitrale occurs when the depolarization of the right atrium and left atrium are both visible in the P wave. 2014 Mar 4;9(3):e90903. In all other situations it is necessary to findthe underlyingcauseand direct treatments towards it. When an OSA event occurs, an attempt is made to breathe with an obstructed airway and the pressure inside the chest is suddenly lowered. Summarizing: The most striking sign of the left atrial enlargement is a wide Pwave, greater than 0.12s or 3small squares, with a predominance of the negative final component in leadV1. Cardiac catheterization. Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, ACC Anywhere: The Cardiology Video Library, CardioSource Plus for Institutions and Practices, Annual Scientific Session and Related Events, ACC Quality Improvement for Institutions Program, National Cardiovascular Data Registry (NCDR). Mitral regurgitation (backward My EKG team recomends you the books that we used to create our website. The ECG has, as one could expect, low sensitivity but high specificity with respect todetecting atrial enlargement. In addition, in lead V1, the depth of the negative final component is greater than the height of the initial part. This upper chamber of your heart receives oxygen-poor blood from your body. Blood and urine tests may be done to check for conditions that affect heart health. In addition to a complete medical history and physical examination, diagnostic procedures for Mitral Valve Prolapse may include any, or a combination, of the following: Electrocardiogram (ECG or EKG). Cardiology 53 years experience. Reddit and its partners use cookies and similar technologies to provide you with a better experience. Left Atrial Enlargement: Left atrial enlargement (LAE) is a marker for diastolic cardiac dysfunction. at home i saw that it said possible left atrial enlargement but dr said nothing about this. Wide P wave with prominent negative component. Read More Created for people with ongoing healthcare needs but benefits everyone. However, each individual may experience symptoms differently. This negative deflection is generally <1 mm deep. No patient met ECG criteria for left atrial abnormality. All rights reserved. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Disclaimer. Chest pain. Habibi M, Samiei S, Ambale Venkatesh B, Opdahl A, Helle-Valle TM, Zareian M, Almeida AL, Choi EY, Wu C, Alonso A, Heckbert SR, Bluemke DA, Lima JA. Hypertension. As it is to be supposed, the dilation of the Left Atrium produces, in most cases, changes in the Pwave, especially in its final component. In fact, it has been considered that the bimodal P wave is better explained because of underlying interatrial block than the longer distance that the impulse has to go across6. The unusual 'P'wave is common in cases of left atrial enlargement. [2] LAE has been found to be correlated to body size, independent of obesity, meaning that LAE is more common in people with a naturally large body size. People with Mitral Valve Prolapse often have no symptoms and detection of a click or murmur may be discovered during a routine examination. In these cases, it is the morphology of the P wave in lead V1 that allows us to determine if there is a left atrial enlargement associated with interatrial block. Patients with tachy-brady syndrome may also necessitate rate controlling drugs (e.g beta-blockers) and anticoagulation (if atrial fibrillation or flutter can be verified). In case of sale of your personal information, you may opt out by using the link. Results of the PAMELA Study. The site is secure. I hope you're alright and the echo gave you some answers! Always consult your doctor for a diagnosis. hospital never told me. National Library of Medicine Get prescriptions or refills through a video chat, if the doctor feels the prescriptions are medically appropriate. Chous electrocardiography in clinical practice, 6th ed. worrisome? You had an ecg. If you have no symptoms/problems because of any structural heart enlargement or defect than there is nothing to be done. Appointments 800.659.7822. 2016 Aug;9(8):10.1161/CIRCIMAGING.115.004299 e004299. border: none; Left atrial enlargement can cause medical problems such as arrhythmias or abnormal heart rhythms. I am guessing your doctor a You should be fine, trust your doctor, that machine reading is quite common. The EKG is just a guidance to help us . The right atrium must then enlarge (hypertrophy) in order to manage to pump blood into the right ventricle. Undefined cookies are those that are being analyzed and have not been classified into a category as yet. could the abnormal been anxiety produced?, and is it something to be worried about? The amplitude of the normal P-wave does not exceed 2.5 mm in anylimb lead. Sinus arrhythmia is a kind of arrhythmia (abnormal heart rhythm). . Medications. This is shown in Figure 1 (upper panel). In Mitral Valve Prolapse, the flaps enlarge and stretch inward toward the left atrium, sometimes "snapping" during systole, and may allow some backflow of blood into the left atrium (regurgitation). [4], Obstructive sleep apnea (OSA) may be a cause of LAE in some cases. Alterations of the mitral valve are the classic causes of left atrial enlargement, both mitral stenosis due to increased pressure, and mitral insufficiency due to volume increase. low voltage qrs Echocardiogram This imaging technique uses sound waves to project a. People with rhythm disturbances may need to be treated with beta blockers or other medications to control tachycardias (fast heart rhythms). It is very common that patients with bradycardia have a strong indication for drugs that aggravate or even cause the bradycardia; in such scenarios, it is generally considered to be evidence based to implement an artificial pacemaker that will allow for drug therapy to continue. This is also a normal finding. Mitral valve prolapse may not cause any symptoms. Primary Mitral Valve Prolapse. 2 weeks dizzy on and off In order to determine if echocardiographic left atrial enlargement is an early sign of hypertensive heart disease, we evaluated 10 normal and 14 hypertensive patients undergoing routine diagnostic cardiac catheterization for echocardiographic left atrial enlargement. Left atrial enlargement (LAE) is due to pressure or volume overload of the left atrium. The length of the P wave in lead II is greater than 120 milliseconds, The downward deflection of the P wave in lead V1 is greater than 40 milliseconds in length, with greater than 1 millimeter negative deflection (< -1 mm in amplitude). Type 1 Brugada ECG pattern (coved type) is abnormal. margin-right: 10px; still having mild vertigo, dizziness and fatigue. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. The murmur is caused by some of the blood leaking back into the left atrium. The negative deflection of biphasic (diphasic) P-waves is generally <1 mm deep. It often affects people with high blood pressure and. By clicking Accept, you consent to the use of ALL the cookies. Based on a work athttps://litfl.com. The presence of two or more borderline ECG findings warrants additional investigation to exclude pathological cardiac disease. [9] By approximating the shape of the left atrium as an ellipsoid, its volume can be calculated from measurements of its dimensions along three perpendicular directions. An enlarged heart (cardiomegaly) describes a heart that's bigger than what is typical. Twitter: @rob_buttner. but I don't see any signs of left atrial enlargement on this EKG. flow of blood), if present at all, is generally mild. Dr. Jerome Zacks answered. 1996 Dec;19(12):954-9. doi: 10.1002/clc.4960191211. (P wave 2.5 mm in II and aVF). Would you like email updates of new search results? Surawicz B, Knilans TK. Benign causes of sinus bradycardia (SB) do not require treatment. low voltage qrs borderline/ normal ecg New York, NY A 29-year-old female asked: Ekg says "borderline ecg" and "probable left atrial enlargement." is this anything of concern? LAE is often a precursor to atrial fibrillation. Bookshelf In secondary Mitral Valve Prolapse, the flaps are not thickened. Circulation. The passage of the electrical stimulus through the atria is reflected in the electrocardiogram as the P wave. 1981 May;47(5):1087-90. doi: 10.1016/0002-9149(81)90217-4. Left bundle branch block always warrants investigation. We conclude that echocardiographic left atrial enlargement may be an early sign of hypertensive heart disease in patients with no other discernible cause of left atrial enlargement. Diego Conde D, Seoane L, et al. Aguilera Saldaa MA, Garca Moreno LM, Rodrguez Padial L, Navarro Lima A, Snchez Domnguez J. Overvad TF, Nielsen PB, Larsen TB, Sgaard P. Thromb Haemost. Cookie Notice . A systematic review. doi: 10.1371/journal.pone.0090903. If your health care provider thinks you have left ventricular hypertrophy, imaging tests may be done to look at the heart. clear: left; The normal P wave measures less than 2.5 mm (0.25 mV) in height and less than 0.12 s in length (3 small squares). is the bulging of one or both of the mitral valve flaps (leaflets) percent of the population. Please enable it to take advantage of the complete set of features! Learn how we can help 290 views Answered >2 years ago Thank A 36-year-old female asked: Surawicz B, et al. For the person with symptoms of dizziness or fainting, maintaining adequate hydration (fluid volume in the blood vessels) with liberal salt and fluid intake is important. The duration of the P-wave will exceed 120 milliseconds in lead II. RBBB is considered a borderline criterion. T-wave inversions in leads V1-V4 are present in 12% of black athletes and are usually preceded by J-point elevation and convex ST segment elevation. Difficulty breathing. Should I be concerned? #mc-embedded-subscribe-form .mc_fieldset { This is caused by too much pressure on the heart, which could be related to high blood pressure, stress, and underlying heart disease. LAE is often a precursor to atrial fibrillation. When in doubt whether the bradycardia is physiological, it is useful to perform a Holter ECG (ambulatory recording). It is mandatory to procure user consent prior to running these cookies on your website. Left atrial enlargement can be mild, moderate or severe depending on the extent of the underlying condition. Other blood pressure drugs. Bays de Luna A, Platonov P, et al. Also known as: Right Atrial Enlargement (RAE), Right atrial hypertrophy (RAH), right atrial abnormality. Beta blockers, angiotensin-converting enzyme . Ekg says "borderline ecg" and "probable left atrial enlargement." #mc_embed_signup { The following are the most common symptoms of Mitral Valve Prolapse. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Interatrial blocks. Tiredness. The cause of Mitral Valve Prolapse is unknown, but is thought to be linked to heredity. If an atrium becomes enlarged (typically as a compensatory mechanism) its contribution to the P-wave will be enhanced. Int J Mol Sci. 1. Analytical cookies are used to understand how visitors interact with the website. The P-wave amplitude is >2.5 mm in P pulmonale. Vaziri SM, Larson MG, Lauer MS, et al. Federal government websites often end in .gov or .mil. Chou's Electrocardiography in Clinical Practice: Adult and Pediatric, Sixth Edition, Saunders, Philadelphia, 2008. The .gov means its official. Also, LAE is a significant risk factor for developing atrial fibrillation. In addition, the function of the heart and the valves may be assessed. One or both of the flaps may not close properly, allowing the blood The Diagnostic Yield of Routine Electrocardiography in Hypertension and Implications for Care in a Southwestern Nigerian Practice. Your findings of low voltage QRS and borderline left atrial enlargement may not be significant, but it is worthwhile to have a cardiologist evaluate y You took a b complex viramin then felt ill and went to ED. If cardiomyopathy or another type of heart condition is the cause of an enlarged heart, a health care provider may recommend medications, including: Diuretics. Symptoms may vary depending on the degree of prolapse present and may include: Palpitations. Ecg borderline left atrial abnormality Ecg borderline left atrial abnormality Share this page Hi, My sister was having a pain on left side under her arm pit and shoulder since a month. Increased vagal tone (e.g., sinus bradycardia, first degree atrioventricular block [AVB]) and increased chamber size due to physiologic remodeling (e.g., left ventricular hypertrophy [LVH], bi-atrial enlargement) account for normal ECG patterns seen in highly trained athletes. All patients had normal coronary arteriography, sinus rhythm, normal left ventricular volumes and function, no valvular disease, and no echocardiographic or ECG left ventricular hypertrophy. 43 year old female. Benign (physiological) causes of bradycardia (e.g vasovagal reaction, well-trained athletes) need not be treated. P-wave is positiv in limb lead II. HHS Vulnerability Disclosure, Help But this change is not associated or caused by anxiet Anxiety isn't a cause of left atrial enlargement. Possible hemiblock: An abnormal right axis plus minimally prolonged qrs duration defines what is termed a left posterior hemiblock (block of the posteroinferior fascicle of the left branch of the bundle of his). Editorial Team Lead, Sports & Exercise Cardiology Clinical Topic Collection. This usually means you have an issue with your heart or lungs that's causing all of this. Accuracy of left atrial enlargement diagnosed by electrocardiography as compared to cardiac magnetic resonance in hypertensive patients. Determinants of left atrial appendage volume in stroke patients without chronic atrial fibrillation. Circ Cardiovasc Imaging. Over time, the repetitive stretching of the left atrium may result in a persistent left atrial enlargement.[5]. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. 2016 Aug 1;116(2):206-19. doi: 10.1160/TH15-12-0923. The first half of the P-wave is therefore a reflection of right atrial activationand the second half is a reflection of left atrial activation. Left atrial enlargement (LAE) or left atrial dilation refers to enlargement of the left atrium (LA) of the heart, and is a form of cardiomegaly. The primary form of Mitral Valve Prolapse is seen frequently in people with Marfan's Syndrome or other inherited connective tissue diseases, but is most often seen in people with no other form of heart disease. Left atrial enlargement (LAE) or left atrial dilation refers to enlargement of the left atrium (LA) of the heart, and is a form of cardiomegaly . The Framingham Heart Study. P-waves with constant morphology preceding every QRS complex. Left atrial enlargement is also referred to as P mitrale, and right atrial enlargement is often referred to as P pulmonale. The Septal Q wave can hint on a possible left sided disease if any. ecg read: Left atrial enlargement can develop too, resulting in problems with how blood is pumped out to the body. 2021 Apr 20;14:1421-1427. doi: 10.2147/IJGM.S282117. High blood pressure and blood volume cause right atrial enlargement. Also known as: Left Atrial Enlargement (LAE), Left atrial hypertrophy (LAH), left atrial abnormality. Electrocardiogram (ECG or EKG). Calculate the heart axis by entering the QRS amplitude inI andIII. It's located in the upper half of the heart and on the left side of your body. If a Type 2 pattern is seen, the ECG needs to repeated to ensure proper lead placement, and a repeat ECG with V1 and V2 in higher intercostal leads should be performed: if there is no evidence of a Type 1 Brugada pattern, no further assessment is required unless there is a history of syncope or relevant family history. Epub 2016 Apr 14. On this Wikipedia the language links are at the top of the page across from the article title. Atrial fibrillation is both cause and effect of left atrial enlargement, although the presence of AF on the EKG makes it difficult to determine left atrial enlargement signs, because P waves are absent4. Hypertension. We are vaccinating all eligible patients. These symptoms include: Fainting. By using our website, you consent to our use of cookies. As the left atrium depolarizes after the right atrium, an enlargement thereof will cause a longer duration of the depolarization time and therefore a widening of the Pwave, greater than 0.12s. Sometimes the right and left component of the Pwave are separated slightly giving the Pwave a form of "letterm" lower case, classically called Pmitrale. I'm 68 fem ale, normal weight, swim 3hours a week, practice QiGong, read more DrKarenB Family Medicine Physician MD 373 satisfied customers Can you please read this? They show how a patient's heart is beating in real-time. had a stress test and holter monitor that came back normal 7 months ago. The atria may become dilated and/or hypertrophic during pathological circumstances. By accepting all cookies, you agree to our use of cookies to deliver and maintain our services and site, improve the quality of Reddit, personalize Reddit content and advertising, and measure the effectiveness of advertising. 2015 Aug 7;16(8):18454-73. doi: 10.3390/ijms160818454. AO 1.8 and ECG criteria independent of left atrial indexed diameter z-score C1: P wave duration 110msec C2 . The https:// ensures that you are connecting to the Without seeing the ecg and only given what you wrote, it isn't possible to know whether the ecg is abnormal or not. While left atrial enlargement can cause chest pain and breathing problems, alerting you to the dangerous condition, right atrial enlargement usually develops with no symptoms at all. The echo sound waves create an image on the monitor as an ultrasound transducer is passed over the heart. Sick sinus syndrome(sinus node dysfunction), which is a common cause of bradycardia, is also discussed separately. poss left atrial enlargement These cookies will be stored in your browser only with your consent. Left Atrial Enlargement (LAE) ECG Review | Learn the Heart - Healio Common abnormal ECG readings that have a low likelihood of correlating with cardiac disease include the following: Isolated atrial enlargement, especially right atrial enlargement; Ectopic atrial rhythms*: right atrial, left atrial, wandering atrial pacemaker at normal rates; First-degree atrioventricular (AV) block; Borderline QTc 0.44-0.45 Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. Left atrial enlargement (LAE) is due to pressure or volume overload of the left atrium. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Reply Weight gain. More information: Bays syndrome and interatrial blocks. Patients with bradycardia due to myocardial ischemia/infarction only demand treatment if cardiac output is compromised or if the bradycardia predisposes to more malign arrhythmias (the algorithm above applies to this situation as well). This website uses cookies to improve your experience while you navigate through the website. J Med Assoc Thai. 1995; 25: 1155-1160. doi: 4. A QTc 500 msec is suggestive of long QT syndrome. Right atrial enlargement produces a peaked P wave ( P pulmonale) with amplitude: > 2.5 mm in the inferior leads (II, III and AVF) > 1.5 mm in V1 and V2. These cookies track visitors across websites and collect information to provide customized ads. The normal P-wave (Figure 1, upper panel) is typically smooth, symmetric and positive. The latter study also showed that the persistent type of AF was associated with LAE, but the number of years that a subject had AF was not. Prognostic Significance of Left Atrial Enlargement in a General Population. Left Atrial Enlargement on the Electrocardiogram Advertising The passage of the electrical stimulus through the atria is reflected in the electrocardiogram as the P wave. Atrial volume index was computed using the biplane area-length method. BMJ 2002;324:1264. doi: 3. Int J Gen Med. #mergeRow-gdpr { Mitral valve prolapse, also known as click-murmur syndrome,

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