Systolic Murmurs Dr Muhammed Aslam Junior Resident Pulmonary Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya
Transcript
Systolic Murmurs Dr Muhammed Aslam Junior Resident Pulmonary
Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya
Definition of murmur Relatively prolonged series of audible
vibrations , Characterized by the timing in cardiac cycle,
intensity (loudness), frequency (pitch), quality, configuration,
duration and direction of radiation Due to disturbance in blood
flow which manifest as turbulence
Description of a Murmur Position in the cardiac cycle ,
configuration or shape Site of best audibility Intensity length
Quality & Pitch Selective Conduction Relation to a
physiological act or maneuver
FREEMAN & LEVINE GRADING GRADE 1GRADE 2GRADE 3GRADE 4GRADE
5GRADE 6- faintest murmur which can be heard only with special
effort. soft but readily audible loud without thrill loud with
thrill heard with steth partially off the chest heard with steth
held off the chest wall.
Classification & types of murmurs Systolic murmur early
systolic, mid systolic, late systolic, pan/holo systolic Diastolic
murmur early diastolic mid diastolic pre systolic Continuous
murmur
Systolic Murmurs
Ejection systolic murmur Most common murmur heard in everyday
practice. Murmur starting after some time interval from first heart
sound and reaching peak by mid-systole or later and ending before
the second heart sound of its origin. It could be PATHOLOGICAL or
INNOCENT/PHYSIOLOGICAL 1. 2. 3. 4. Ventricular outflow obstruction
Dilation of aorta and pulmonary trunk Accelerated systolic flow
into aorta or pulmonary trunk Innocent midsystolic murmur(
including those due to morphological changes of valve with no
obstruction)
Ventricular outflow obstruction
Causes of Left Ventricular Outflow Obstruction Valvular a)
Rheumatic b) Congenital- bicuspid and unicuspid valve c)Myxoid
dysplasia d)Annular Hypoplasia e)Calcific Degenerative f)Hyper
lipidemia g) Fabrys disease h) Infective endocarditis i)
Ochronosis
Causes of Left Ventricular Outflow Obstruction Supra Valvular
a) Congenital Hour glass type , Diffuse type , Discrete membrane b)
Aortic Dissection c) Homozygous type 2 hyperlipidemia d) Healing
Aortotomy site e) Rubella
Causes of Left Ventricular Outflow Obstruction Sub valvular a)
Dynamic HOCM b) Discrete (Membranous) Sub Aortic Stenosis c) Tunnel
Aortic Stenosis
Aortic Stenosis Iso Volumetric Contraction - ventricular
pressure increases -opening of Aorta and pulmonary valve- ejection
commences and murmur begins Ejection increases -murmur becomes
crescendo Ejection declines -murmur in decrescendo Murmur ends
before ventricular pressure drops below aortic pressure at which
aortic valve and pulmonary valve closes generating a2 and p2
Murmur Of Valvular Aortic Stenosis Site Of Best Audibility
Aortic Area -conducted to carotid (best heard with the patient
sitting up, leaning forwards and breath held in expiration). Also
heard at left sternal border and apex Character- Harsh or rough
quality
Site of Best Audibility And Significance in Aortic Stenosis
Best audible at right 2nd space , conducted in right carotid
Valvular non calcific AS Best audible in left sternal border , no
carotid conduction Sub valvular AS , calcific AS , mistaken VSD ,
mistaken MR Carotid murmur with or without right Supra valvular AS
, carotid stenosis second space murmur Audible only at apex
Calcific AS in elderly with emphysema , mistaken for MR
Longer the murmur and later in systole the murmur peaks , the
more severe the Aortic stenosis , when cardiac out put is within
normal limits Severity is over estimated in high cardiac output
states and under estimated in low cardiac output states.
Aortic Stenosis At times, as one moves downwards from aortic
area to mitral area, the murmur initially becomes softer and then
again increases in intensity. This phenomenon is known as
'hourglass conduction'. In calcific aortic stenosis, the murmur is
loud and harsh in the aortic area, but it has a musical quality
along the left sternal border and at apex. This difference in
quality of the same murmur at two different sites is referred to as
`Gallavardin phenomenon
Influence Of Various Maneuver In Aortic Stenosis Manaeuver
Fixed Obstruction Dynamic Obstruction Respiration No change May
with inspiration Standing Valsalva Squatting
HOCM Dynamic LVOT obstruction Murmur will increase in intensity
with any manoeuvre that decreases the volume of blood in the left
ventricle (such as standing abruptly or the strain phase of a
valsalva manoeuvre ) Administration of amyl nitrite will also
accentuate the murmur by decreasing venous return to the heart.
Classically, the murmur is loudest at the left parasternal edge,
4th intercostal space
PS Murmur Best audible at left 2nd or 3rd ICS , but is also
audible at fourth space along left sternal border. Conducted to
supra clavicular area and left side of neck
Site of best audibility / conduction Significance Left second
space Valvular PS Infraclavicular and away from midline Supra
valvular PS Left 3rd or 4th space Infundibular PS or double
chambered RV Right second or third space PS with TGA Conduction to
left side of neck Valvular PS Failure of conduction to left side
Valvular PS is less likely Ventricular septal diffect is more
likely Infundibular PS is likely
Louder ,longer and late peaking murmur is associated with more
severe PS . PS murmur is selectively conducted to the
infraclavicular region and the left side of neck PS murmur during
inspiration and during straining phase of valsalva maneuver
Other causes of MSM Dilation of Aorta & Pulmonary trunk
Short soft midsystolic murmur Left sided murmurs in marfans
syndrome, syphilis Right sided murmurs in idiopathic dilation of
pulmonary artery, pulmonary hypertension MSM of Hyperdynamic
circulation Normal aorta or pulmonary trunk but increased flow
Anaemia, pregnancy, fever, thyrotoxicosis
Other causes of MSM OS-ASD Rapid flow across pulmonary valve to
dilated pulmonary trunk Pure AR Due to Accelerated LV ejection
Pan Systolic/ Holo Systolic Murmur Flow from a chamber or
vessel whose pressure or resistance throughout systole is higher
than pressure or resistance of the chamber receiving the flow
Mitral Regurgitation Tricuspid Regurgitation Ventricular Septal
Defect Aorto Pulmonary Window Patent Ductus Arteriosus with
PAH
Mitral Regurgitation S1 to S2 provided MV remains incompetent
and gradient remains Holosystolic Early systolic Late systolic
Sometimes MSM Best audible at apex Radiates to left axilla and back
becos jet directed posterolaterally in LA LLSB when jet directed
against atrial septum near base of aorta
Mitral Regurgitation Usually 3/6 grade Presence of systolic
thrill suggest chordal rupture, IE with vegetations, AS or VSD
mistaken as MR Soft and blowing or musical in character
Mitral Regurgitation Relation with various maneuvers Decreases
on standing and valsalva Increases with supine
Tricuspid Regurgitation Best audible at tricuspid area (left
4th space) No selective conduction but is often heard to right of
sternum Higher the frequency and longer the murmur , more the right
ventricle pressure
Tricuspid Regurgitation Rivero Carvallos sign TR murmur
increases during inspiration Increased VR increased RV volume
Increased SV velocity of regurgitant flow increases Sometimes TR
heard only during inspiration Carvallos sign disappears in RV
failure
Ventricular Septal Defect Size of VSD is the most important
determinant of Auscultatory findings.Other determinants are PAH,
Location of defect , and associated defects. Best audible along the
left sternal border anywhere from 2nd to 4th spaces and is not
selectively conducted to any where. In supracristal VSD murmur is
best heard at pulmonary area and may be selectively conducted to
the infraclavicular area and the left side of neck
Ventricular Septal Defect Intensity usually above 4/6 grade
Rough or Harsh in character Better heard during expiration and is
diminished with inspiration Usually appear between 2-6 weeks after
birth
Other PSM Aorto Pulmonary Window with PAH Otherwise continuous
murmur Diastolic component reduced with increasing PAH PDA with PAH
Similar mechanism
Early Systolic Murmurs Begin with the first sound and peak in
the first third of systole. Common causes are a small ventricular
septal defect (VSD), VSD with PVR or the innocent murmurs of
childhood. Other causes are Acute Mitral Regurgitation and Normal
pressure TR, Organic TR
LSM MVP Leaflets remains competent during early ventricular
contraction but overshoot in late systole One or more mid systolic
clicks precede murmur [sudden deceleration of the column of blood
against the prolapsed leaflet or scallops] Any maneuver that
decreases left ventricular volume such as standing, sitting,
Valsalva maneuver ,and amyl nitrate inhalation can produce earlier
onset of clicks, longer murmur duration, and decreased murmur
intensity. Any maneuver that increases left ventricular volume such
as squatting, elevation of legs, hand grip, and phenylephrine can
delay the onset of clicks, shorten murmur duration, and increase
murmur intensity. Other LSM- papillary muscle dysfunction ,
Tricuspid valve prolapse