Transposition of the great arteries, right aortic arch, coarctation, and isolation of the left subclavian artery: report of surgical therapy.

ruptured chordae tendineae. Pathologic examination revealed scarring and myxomatous degeneration of the mitral valve. The origin of the systolic murmur, mimicking that of aortic stenosis, is well documented to be due to a regurgitant jet striking the anterosuperior wall of the left atrium adjacent to the aorta, thus producing radiation toward the carotid arteriessm5 However, the cause of the diastohe murmur, mimicking aortic regurgitation, is not so well defined. Pulmonic insufficiency is made unlikely by the location of the murmur in the aortic region and by its timing, beginning before the pulmonic closure sound. Mitral flow murmurs tend to be rumbling and middiastolic, while the murmur in this case was high-pitched and early diastolic. Given the timing of the diastolic murmur, coincident with the continued early diastohc mitral prolapse, we believe the murmur was due to turbulence created by the flail leaflet describing a rapid movement from its prolapsed position in the left atrium to the open position in the left ventricle, in the face of the onrush of blood from a volume-overloaded left atrium in early diastole.