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A "murmur on top of the head" has been documented in seven patients with mitral insufficiency. Five patients revealed ruptured chordae tendineae of anterior leaflets secondary to rheumatic fever or subacute bacterial endocarditis. Two remaining patients exhibited rheumatic valvulitis and annular dilatation. The regurgitation was readily corrected by excising or plicating the flail area or posteromedial annuloplasty, or both. Survivors are asymptomatic without embolization or infection. Whether due to ruptured chordae of the aortic leaflet (usual) or valvulitis and annular dilatation (and in the absence of valvular calcification by fluoroscopy), the problem has been correctable by iow-risk reconstructive procedures without need for prosthetic valve replacement. Therefore, when this murmur is present, valuable inferences regarding etiology, pathology, surgical therapy, and prognosis can be made.
Merendino KA, Hessel EA. The "Murmur on Top of the Head" in Acquired Mitral Insufficiency: Pathological and Clinical Significance. JAMA. 1967;199(12):892–896. doi:10.1001/jama.1967.03120120080012
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