Download - Dr. R. Tandon Sitaram Bhartia Institute, New Delhi.

Dr. R. TandonSitaram Bhartia Institute, New Delhi

Continuous MurmursContinuous Murmurs

Defn.Defn. :- :- A murmur starting in systole and A murmur starting in systole and

going through the S2 in diastole.going through the S2 in diastole.

A murmur present throughout the A murmur present throughout the cardiac cycle : covers S1, S2 whole cardiac cycle : covers S1, S2 whole of systole and diastole, may be of systole and diastole, may be louder in systole or diastole.louder in systole or diastole.


To & fro murmurTo & fro murmur :- :-

A gap between the systolic and A gap between the systolic and diastolic murmurs identifies diastolic murmurs identifies two separate murmurs.two separate murmurs.


Clinical SettingClinical Setting :- :- Cyanotic or acyanotic.Cyanotic or acyanotic. Features of aortic run offFeatures of aortic run off

- present, absent.- present, absent. Features of hyperkinetic circ.Features of hyperkinetic circ.

- present, absent.- present, absent. Cardiac chambers involvedCardiac chambers involved

- all or partial.- all or partial.


Acyanotic patientsAcyanotic patients :- :-

PDA PDA S. of Valsalva-RA/RV S. of Valsalva-RA/RV

fistulafistulaCoron. AV fistulaCoron. AV fistulaSystemic AV fistula.Systemic AV fistula.Coarctation of the aortaCoarctation of the aorta

Peripheral PS.Peripheral PS.Anom. LCA from PA.Anom. LCA from PA.AP window.AP window.MS with small ASD.MS with small ASD.Venous hum.Venous hum.Post traumatic.Post traumatic.


Cyanotic patientsCyanotic patients :- :- Bronchial collat. in TOF physiologyBronchial collat. in TOF physiology PDA in TOF physiologyPDA in TOF physiology TAPVCTAPVC Pulm. AV fistulaPulm. AV fistula PTAPTA Surgical shuntsSurgical shunts


T.O.F. PhysiologyT.O.F. Physiology :- :- Fallot’s tetralogyFallot’s tetralogy Tricuspid atresiaTricuspid atresia DORV with VSD & PS/PADORV with VSD & PS/PA TGA with VSD & PS/PATGA with VSD & PS/PA Single vent. With PS / PASingle vent. With PS / PA Miscellaneous malpositions with Miscellaneous malpositions with

VSD & PS/PA.VSD & PS/PA.

Continuous MurmursContinuous MurmursPDAPDA :- :- Max intensity ULSB. Thrill Max intensity ULSB. Thrill ±± Systolic component louder, harsh broken Systolic component louder, harsh broken

into multiple clicks.into multiple clicks. Diastolic component smooth and Diastolic component smooth and

decrescendo.decrescendo. Hollow characterHollow character Peaks at S2.Peaks at S2. With PAH the diastolic component With PAH the diastolic component

becomes shorter and may disappear .becomes shorter and may disappear . May be palpable as systolic or cont. thrill.May be palpable as systolic or cont. thrill.

S1 S2 S1

CM

x


Sinus of Valsalva fistulaSinus of Valsalva fistula :- :- Palpable as cont. thrill.Palpable as cont. thrill. Loud grade V / VI.Loud grade V / VI. May mask both S1 and S2May mask both S1 and S2 Louder systolic component if VSD is Louder systolic component if VSD is

present.present. Louder diastolic component if AR is Louder diastolic component if AR is

present.present. Both VSD and AR may be present.Both VSD and AR may be present.


Sinus of Valsalva fistulaSinus of Valsalva fistula :- :- Louder at RSB if in RA.Louder at RSB if in RA. Louder at MLSB if in RV.Louder at MLSB if in RV.

Systolic component may be softer.Systolic component may be softer.

S1 S2 S1

CM


Coron. AV fistulaeCoron. AV fistulae :- :- Relatively uncommon.Relatively uncommon. CM – 2 to 6 in intensity.CM – 2 to 6 in intensity. Mid to lower L, RSB.Mid to lower L, RSB. Shunt size usually small.Shunt size usually small. Myocard. isch. uncommonMyocard. isch. uncommon


Syst. AV fistulaeSyst. AV fistulae :- :- Intra cranial, intrahepatic, chest wall, Intra cranial, intrahepatic, chest wall,

abdomen, extremities.abdomen, extremities. CM. grade 2 to 4, midsystolic and CM. grade 2 to 4, midsystolic and

diastolic peaks.diastolic peaks. Depending on size of shunt; features Depending on size of shunt; features

of (a) aortic runoff (b) hyperkinetic of (a) aortic runoff (b) hyperkinetic circ state (c) circ state (c) syst. ven. pr. (d) CCF syst. ven. pr. (d) CCF specially neonates.specially neonates.


Coarctation of the AoCoarctation of the Ao :- :- Systolic hypertension arms.Systolic hypertension arms.

Systolic pr. diff between upper Systolic pr. diff between upper and lower segment – ejection and lower segment – ejection syst. m.syst. m.

Identical diast. pr. – no diast. m.Identical diast. pr. – no diast. m.

Cont. murmurs rare.Cont. murmurs rare.


Peripheral PSPeripheral PS :- :-

Systolic gradient between proximal and Systolic gradient between proximal and distal segments – ejection syst. m.distal segments – ejection syst. m.

No diastolic gradientNo diastolic gradientno diastol. or CM.- no diastol. or CM.

Rarely a diastolic gradient may be present Rarely a diastolic gradient may be present & CM.& CM.

Acyanotic; PAH Acyanotic; PAH ±±

Continuous MurmursContinuous MurmursALCAPAALCAPA :- :-

High PA pr. perfuses LCA at birth.High PA pr. perfuses LCA at birth.

↓ ↓ PVR by 3-6 wks - myocard. ischaemia - PVR by 3-6 wks - myocard. ischaemia - anterolat. M.I.anterolat. M.I.

Rarely good collaterals from RCA to LCA.Rarely good collaterals from RCA to LCA.- Present in childhood or later as a CM with - Present in childhood or later as a CM with

small L to R shunt.small L to R shunt.

Dx. : Echo; RCA angio.Dx. : Echo; RCA angio.


AP WindowAP Window :- :- Relatively rare anomaly.Relatively rare anomaly. Usually large defects hence no Usually large defects hence no

CM.CM. 1-2% small. Atypical loud CM at 2 1-2% small. Atypical loud CM at 2

or 3 LICS.or 3 LICS. Dx. Difficult. Site of m. unusual for Dx. Difficult. Site of m. unusual for

PDA.PDA.


MS with small ASDMS with small ASD :- :- Findings of MS.Findings of MS. Loud venous hum at ¾ RSB.Loud venous hum at ¾ RSB. Louder in systole and expiration.Louder in systole and expiration. ? Is frequency higher.? Is frequency higher.


Venous humVenous hum :- :- Common upto 6 to 8 yrs.Common upto 6 to 8 yrs. RSB, above clavicle, child RSB, above clavicle, child

sitting up.sitting up. Intensity Intensity with inspiration. with inspiration. May disappear : head to left, May disappear : head to left,

pressure above clavicle, lying pressure above clavicle, lying down.down.


TOF PhysiologyTOF Physiology : : Severe obstr. Or PA.Severe obstr. Or PA. Bronchial or Aorto pulm. collaterals Bronchial or Aorto pulm. collaterals

perfuse PA.perfuse PA. Soft venous hum like CM.Soft venous hum like CM.

- Chest wall, interscapular area.- Chest wall, interscapular area. Large flow – louder m.Large flow – louder m.

- Mild cyanosis, LVE, Ao. runoff - Mild cyanosis, LVE, Ao. runoff ±.±. If PDA – usual site, m. can be atypical.If PDA – usual site, m. can be atypical.


TAPVCTAPVC :- :- CM : SSN, upper RSB, CM : SSN, upper RSB, flow, no obstr. flow, no obstr. Infradiaphragmatic : CM in Infradiaphragmatic : CM in

epigastrium, over the liver.epigastrium, over the liver. Obstr. site of PV entry to syst. V. / RA.Obstr. site of PV entry to syst. V. / RA. Features of severe PAH less common Features of severe PAH less common

with CM.with CM.


Pulm. AVFPulm. AVF :- :- Unexplained cyanosis.Unexplained cyanosis. Hemoptysis, embolism, brain Hemoptysis, embolism, brain

abscess.abscess. No CE, S1 & S2 normal, no m.No CE, S1 & S2 normal, no m. ECG normal.ECG normal. Cont. m. over chest wall.Cont. m. over chest wall. Chest x-ray may identify.Chest x-ray may identify. Contrast : left brachial inj.Contrast : left brachial inj.


Persistent truncusPersistent truncus :- :- Ejection syst. m. ends before A2.Ejection syst. m. ends before A2. Truncal regurg. m. starts with A2.Truncal regurg. m. starts with A2. Usually to & fro m.Usually to & fro m. Rarely PA osteal stenosis may result in Rarely PA osteal stenosis may result in

CM.CM. Dx. : Echo DopplerDx. : Echo Doppler


VSD with ARVSD with AR :- :- Pansyst. m masks S1 and S2.Pansyst. m masks S1 and S2. AR m. starts with A2.AR m. starts with A2. No gap at upper LSB.No gap at upper LSB. Below Lt. clavicle m. character → to Below Lt. clavicle m. character → to

and fro.and fro.


AS with ARAS with AR :- to & fro. m. :- to & fro. m. AS m. ends before A2.AS m. ends before A2. AR m starts from A2.AR m starts from A2. Gap easily appreciable should Gap easily appreciable should

not be mistaken for a CM.not be mistaken for a CM.

S1 S2 S1

X ESM ARM


Acyanotic patientsAcyanotic patients : Physiol. effects : Physiol. effects L L → R shunt→ R shunt Vol overload of circ. Vol overload of circ. Hyperkinetic circ. State Hyperkinetic circ. State ↓ SVR, ↓ SVR, CO, CO,

HR and SVHR and SV Plasma vol.Plasma vol. Aortic runoff.Aortic runoff.


Acyanotic patientsAcyanotic patients : Physiol. effects : Physiol. effects syst. ven. pr.syst. ven. pr. M VOM VO22.. Ao diast. Pr.Ao diast. Pr. Myocard.Myocard. LV edp.LV edp. IschaemiaIschaemia diast. Filling timediast. Filling time


Cyanotic patientsCyanotic patients : Physiol. effects : Physiol. effects Depend on anomalyDepend on anomaly Pulm. AVFPulm. AVF

- - PVR in fistula PVR in fistula

- - PVR non affected area PVR non affected area

- R - R → L shunt – cyanosis→ L shunt – cyanosis

- Potential for paradox embolism, - Potential for paradox embolism, brain abscess, hemoptysis. brain abscess, hemoptysis.

S1 S2 S1

S1 S2 S1

S1 S2 S1

X ESM ARM

CM

CM