JAWAHARLAL INSTITUTE OF POST-GRADUATE MEDICAL JAWAHARLAL INSTITUTE OF POST-GRADUATE MEDICAL EDUCATION AND RESEARCH PONDICHERRY EDUCATION AND RESEARCH PONDICHERRY

(An Institution of National Importance under the Ministry of Health (An Institution of National Importance under the Ministry of Health Government of India )Government of India )

AUSCULTATION OF THE AUSCULTATION OF THE HEARTHEART

BALACHANDER JBALACHANDER JDIRECTOR-PROFESSOR & DIRECTOR-PROFESSOR &

HEADHEADDEPARTMENT OF DEPARTMENT OF

CARDIOLOGYCARDIOLOGYJIPMER PONDICHERRYJIPMER PONDICHERRY

SCOPE OF THE LECTURESCOPE OF THE LECTURE

RHEUMATIC VALVULAR HEART RHEUMATIC VALVULAR HEART DISEASESDISEASES

NON-RHUEMATIC VALVULAR HEART NON-RHUEMATIC VALVULAR HEART DISEASESDISEASES

CONGENITAL HEART DISEASESCONGENITAL HEART DISEASESMYOCARDIAL DISEASESMYOCARDIAL DISEASESPERICARDIAL DISEASEPERICARDIAL DISEASE

RHEUMATIC VALVULAR HEART RHEUMATIC VALVULAR HEART DISEASEDISEASE

MITRAL STENOSISMITRAL STENOSIS MITRAL REGURGITATIONMITRAL REGURGITATION AORTIC STENOSISAORTIC STENOSIS AORTIC REGURGITATIONAORTIC REGURGITATION TRICUSPID STENOSIS.TRICUSPID STENOSIS. TRICUSPID REGURGITATIONTRICUSPID REGURGITATION MULTIVALVULAR DISEASES AND COMBINATIONSMULTIVALVULAR DISEASES AND COMBINATIONS A. MS+MRA. MS+MR B. MS +ARB. MS +AR C. MS+TRC. MS+TR D. MS+ASD. MS+AS E.MS+AS+ARE.MS+AS+AR F.MS+AS+TSF.MS+AS+TS G.MR+ARG.MR+AR H.MR+ASH.MR+AS IMPACT OF AFIMPACT OF AF

MITRAL STENOSISMITRAL STENOSIS

AUSCULTATIONAUSCULTATION

THE FIRST HEART SOUND S1 IN THE FIRST HEART SOUND S1 IN MSMS

REVERSED SPLITTING OF S1REVERSED SPLITTING OF S1 M1 PRECEDES T1M1 PRECEDES T1 LOUD S1 CLOSING SNAPLOUD S1 CLOSING SNAP AF AND M1AF AND M1 TYPE 1: MS IS MILD M1 DOES NOT BECOME LOUD TYPE 1: MS IS MILD M1 DOES NOT BECOME LOUD

AFTER LONG DIASTOLES.AFTER LONG DIASTOLES. TYPE 2: SEVERE STENOSIS AND CALCIFICATION: TYPE 2: SEVERE STENOSIS AND CALCIFICATION:

M1 LOUDNESS DIRECTLY PROPORTIONAL TO M1 LOUDNESS DIRECTLY PROPORTIONAL TO LENGTH OF PREVIOUS DIASTOLES.LENGTH OF PREVIOUS DIASTOLES.

TYPE 3: MOD STENOSIS AND PLIABLE: M1 TYPE 3: MOD STENOSIS AND PLIABLE: M1 LOUDNESS INVERSELY PROPORTIONAL TO LOUDNESS INVERSELY PROPORTIONAL TO LENGTH OF PREVIOUS DIASTOLES.LENGTH OF PREVIOUS DIASTOLES.

Phonocardiographic (Phono) recording from a patient with mitral stenosis showing theloud intensity first heart sound caused by the loud mitral component M1.

Diagrammatic illustration of the left ventricular (LV) and left atrial (LA) pressure curvesin a patient with mitral stenosis showing the diastolic pressure gradient between LA and the LVreflecting the mitral stenosis. When the rising LV pressure with onset of systole exceeds that ofthe LA, the mitral valve will close. Note that the tangent to LV pressure drawn at the point of thecrossover of the two pressure curves during this phase of LV systolic pressure rise is steep,showing that the ventricle has achieved a faster rate of contraction and higher dP/dt.

THE SECOND HEART THE SECOND HEART SOUND IN MSSOUND IN MS

THE LOUDNESS OF P2 THE LOUDNESS OF P2 CORRESPONDS WITH THE DEGREE CORRESPONDS WITH THE DEGREE OF PULMONARY HYPERTENSIONOF PULMONARY HYPERTENSION

S1 LOUDER AT THE BASE THAN S1 LOUDER AT THE BASE THAN S2 EXTRA LOUD S1S2 EXTRA LOUD S1

NORMAL OR NARROW SPLITTINGNORMAL OR NARROW SPLITTING

THE OPENING SNAPTHE OPENING SNAPCAUSES OF MITRAL OPENING SNAPCAUSES OF MITRAL OPENING SNAP1.1. MITRAL STENOSISMITRAL STENOSIS2.2. DOMINANT MR DUE TO POST DOMINANT MR DUE TO POST

LEAFLETLEAFLET3.3. VSDVSD4.4. PDAPDA5.5. TRICUSPID ATRESIATRICUSPID ATRESIA6.6. THYROTOXICOSISTHYROTOXICOSIS7.7. BT SHUNT FOR TOFBT SHUNT FOR TOF8.8. CONGENITAL MS?CONGENITAL MS?9.9. MITRAL VALVE PROLAPSEMITRAL VALVE PROLAPSE10.10. MASSIVE ASCITES (PSEUDO-KNOCK MASSIVE ASCITES (PSEUDO-KNOCK

SOUND)SOUND)11.11. TUMOR PLOP OF LA MYXOMATUMOR PLOP OF LA MYXOMA

Phonocardiogram (Phono) recording taken at the apex area from a patient withrheumatic mitral stenosis who had a previous mitral valve commissurotomy for relief of theobstruction. The S1 is relatively loud. Note a sharp sound following the S2, which is the openingsnap (OS). The OS occurs almost simultaneously with the most nadir point of the apex tracing,which is termed the O point.

Stop frame of a two-dimensional echocardiogram from a patient with mitral stenosis inthe parasternal long axis at onset of diastole showing the typical bowing of the anterior mitralleaflet (arrow). Note that the leaflet tip is pointing posteriorly because of tethering caused by thestenosis making a funnel-like opening. Part of the column of blood trying to enter the left ventricle(LV) from the left atrium (LA) during diastole is oriented toward the belly of the leaflet. Whenthe leaflet excursion reaches its anatomical limits caused by the tethering, this column of bloodis suddenly decelerated. This leads to the production of the opening snap (OS).

OTHER CAUSES OF MITRAL OSOTHER CAUSES OF MITRAL OS

VSDVSDPDAPDATRICUSPID ATRESIATRICUSPID ATRESIATHYROTOXICOSISTHYROTOXICOSISAFTER BT SHUNTAFTER BT SHUNT? CONGENITAL MS? CONGENITAL MS?TUMOR PLOP OF LA MYXOMA?TUMOR PLOP OF LA MYXOMA

THE 2-OS INTERVAL AND THE THE 2-OS INTERVAL AND THE SEVERITY OF MSSEVERITY OF MS

FACTORS CONTROLLING FACTORS CONTROLLING DURATION OF THE 2-OS DURATION OF THE 2-OS INTERVAL AREINTERVAL ARE

1.1. LA PRESSURE AT MV OPENING.LA PRESSURE AT MV OPENING.2.2. THE HEART RATE.THE HEART RATE.3.3. THE STIFFNESS OF MVTHE STIFFNESS OF MV4.4. LV CONTRACTILITY AND LV CONTRACTILITY AND

RELAXATIONRELAXATION5.5. AV CLOSING PRESSUREAV CLOSING PRESSURE

Note that the distance between the A2 and the OS is shorter with the higher left atrial pressure.

A) Diagram showing simultaneous left ventricular (LV) and left atrial (LA) pressuresin mild, moderate, and severe degrees of mitral stenosis. The more severe the stenosis, the higherwill be the left atrial pressure. The opening snap (OS) occurs at the end of the isovolumicrelaxation phase of the left ventricle when the left ventricular pressure falls just below the leftatrial pressure. The OS will therefore tend to occur earlier with higher LA pressure and later withlower LA pressure. Thus, the S2-OS interval is short with severe mitral stenosis and long withmild mitral stenosis. (B) Visual representation of the excursion of the mitral leaflets in mitralstenosis of different degrees of severity: a, normal; b, mild; c, moderate; d, severe. With milderstenosis the column of blood has to travel further before deceleration against the valve, therebymaking a late OS.

CAUSES OF A LATE OSCAUSES OF A LATE OS

1.1. MILD DEGREE OF MSMILD DEGREE OF MS2.2. CALCIFIED MVCALCIFIED MV3.3. BRADYCARDIABRADYCARDIA4.4. POOR MYOCARDIAL FUNCTIONPOOR MYOCARDIAL FUNCTION5.5. AORTIC REGURGITATION.AORTIC REGURGITATION.6.6. LARGE LA LOW LA PRESSURE LOW LARGE LA LOW LA PRESSURE LOW

FLOW.FLOW.7.7. HIGH AORTIC PRESSUREHIGH AORTIC PRESSURE

SOFT OR ABSENT OS IN MSSOFT OR ABSENT OS IN MS OBESITYOBESITY EMPHYSEMAEMPHYSEMA MV CALCIFICATIONMV CALCIFICATION FIBROSISFIBROSIS CONGENITAL MSCONGENITAL MS LOW FLOW DUE TO A. SEVERE MSLOW FLOW DUE TO A. SEVERE MS B. SEVERE PAHB. SEVERE PAH C. AS OR TSC. AS OR TS D. MYOCARDIAL DYSFND. MYOCARDIAL DYSFN LARGE RVLARGE RV MOD TO SEVERE ARMOD TO SEVERE AR

Note that the higher the aortic pressure the longer the A2-OS interval.

DIFFERENTIATING A2-P2 FROM DIFFERENTIATING A2-P2 FROM A2-OSA2-OS

If the second component of a split S2 is louder or as, If the second component of a split S2 is louder or as, loud at the apex as elsewhere, it is probably an OS.loud at the apex as elsewhere, it is probably an OS.

If the second component of an S2 split becomes softer If the second component of an S2 split becomes softer on inspiration at the lower left sternal border (in the on inspiration at the lower left sternal border (in the absence of LBBB), it is probably a mitral OS.absence of LBBB), it is probably a mitral OS.

A widely split S2 on inspiration, that appears to become, A widely split S2 on inspiration, that appears to become, wider on expiration is an OS, in the absence of LBBB. wider on expiration is an OS, in the absence of LBBB.

A triple second sound, in which the three sounds are A triple second sound, in which the three sounds are close enough together to sound like a snare-drum, close enough together to sound like a snare-drum, implies than an OS is present as the final component.implies than an OS is present as the final component.

If a split second sound becomes wider on standing, its, If a split second sound becomes wider on standing, its, second component is an OS.second component is an OS.

If the S1 is soft the second component of the S2 is not If the S1 is soft the second component of the S2 is not likely to be an OS. likely to be an OS.

On inspiration, the S2 split opened up into its A2 and P2 components. Together with the OS, a triple second sound is heard that produces a snare-drum effect.

DIFFERENTIAL DIAGNOSIS OF A DIFFERENTIAL DIAGNOSIS OF A MITRAL OPENING SNAPMITRAL OPENING SNAP

The early S3 of constrictive pericarditis – The early S3 of constrictive pericarditis – “Pericardial Knock”“Pericardial Knock”

The Tumor-plop of a left atrial myxoma.The Tumor-plop of a left atrial myxoma.

A vegetation on the mitral valve that A vegetation on the mitral valve that moves rapidly form the left atrium into moves rapidly form the left atrium into the LV and strikes the base of the the LV and strikes the base of the ventricular septum.ventricular septum.

THE S3 AND MITRAL STENOSISTHE S3 AND MITRAL STENOSIS If the Diastolic murmur of MS begins with a loud If the Diastolic murmur of MS begins with a loud

sound, that sound is probably on S3.sound, that sound is probably on S3. In the French literature the loud S3-like In the French literature the loud S3-like

beginning of the diastolic murmur has been beginning of the diastolic murmur has been called the “initial jerk” of the MS murmur. called the “initial jerk” of the MS murmur.

A right ventricular S3 may be heard in MS if the A right ventricular S3 may be heard in MS if the right atrial pressure is high and the RV is dilated right atrial pressure is high and the RV is dilated due to pulmonary hypertension and congestive due to pulmonary hypertension and congestive failure. If the enlarged RV usurps the apex area, failure. If the enlarged RV usurps the apex area, the S3 may be heard well into the middle of the the S3 may be heard well into the middle of the left thorax and may be mistaken for an LVS3. left thorax and may be mistaken for an LVS3.

THE DIASTOLIC MURMUR OF THE DIASTOLIC MURMUR OF MITRAL STENOSIS :MITRAL STENOSIS :

The diastolic murmur of MS begins just after the The diastolic murmur of MS begins just after the opening snap (OS). opening snap (OS).

This means that there must be a pause due to This means that there must be a pause due to isovolumic relaxation between the A2 and the isovolumic relaxation between the A2 and the diastolic murmur. diastolic murmur.

Because of the pause that usually occurs after Because of the pause that usually occurs after the S2, the MS murmur is called an early the S2, the MS murmur is called an early delayed diastolic murmur. delayed diastolic murmur.

The typical shape of the diastolic murmur of MS The typical shape of the diastolic murmur of MS on auscultation is initial crescendo, decrescendo on auscultation is initial crescendo, decrescendo rumble and late crescendo upto to the M1. rumble and late crescendo upto to the M1.

The crescendo murmur to the M1 The crescendo murmur to the M1 in MS (“Presystolic murmur”) :in MS (“Presystolic murmur”) :

As the mitral orifice is reduced by LV contraction, the velocity of flow As the mitral orifice is reduced by LV contraction, the velocity of flow increases as long as the pressure is higher in the left atrium than in increases as long as the pressure is higher in the left atrium than in the LV.the LV.

In AF the late crescendo occurs at the end of short diastoles In AF the late crescendo occurs at the end of short diastoles because only during short diastoles is the left atrial pressure high because only during short diastoles is the left atrial pressure high enough to maintain high-velocity flow during pre-isovolumic enough to maintain high-velocity flow during pre-isovolumic contraction. It requires a gradient of more than 10mmHg at the contraction. It requires a gradient of more than 10mmHg at the onset of LV contraction to create a crescendo murmur to the M1.onset of LV contraction to create a crescendo murmur to the M1.

The presence of a crescendo murmur to the M1 indicates that the The presence of a crescendo murmur to the M1 indicates that the valve must be sufficiently flexible to change the size of the orifice; valve must be sufficiently flexible to change the size of the orifice; that is, it must not be rigidly calcified (although it may be too fibrosed that is, it must not be rigidly calcified (although it may be too fibrosed or calcified for a valvotomy).or calcified for a valvotomy).

Important MR complicating MS can eliminate this pre-M1 Important MR complicating MS can eliminate this pre-M1 accentuation even in sinus rhythm.accentuation even in sinus rhythm.

FACTORS INCREASING MS FACTORS INCREASING MS MURMUR LOUDNESSMURMUR LOUDNESS

ExpirationExpiration Healthy LVHealthy LV Concomitant MRConcomitant MRA Grade 4/6 MS murmur –at least A Grade 4/6 MS murmur –at least

Moderate Stenosis in the absence of Moderate Stenosis in the absence of MRMR

If MS murmur radiates to the baseIf MS murmur radiates to the base1.1. Severe MSSevere MS2.2. No Systemic levels of PAHNo Systemic levels of PAH

MANEVERS TO INCREASE THE MANEVERS TO INCREASE THE MS MURMUR INTENSITYMS MURMUR INTENSITY

CoughingCoughingPost-Valsalva Release PhasePost-Valsalva Release PhaseSlow down Heart RateSlow down Heart RateSquatting : Increase CO for a few beatsSquatting : Increase CO for a few beatsHand-Grip : Increase CO, Increase HRHand-Grip : Increase CO, Increase HRExerciseExerciseAmyl NitriteAmyl Nitrite

FACTORS SOFTENING THE MS FACTORS SOFTENING THE MS MURMURMURMUR

Mild MSMild MS ObesityObesity EmphysemaEmphysema Low FlowLow Flow A large RV pushing the LV PosteriorlyA large RV pushing the LV Posteriorly Coincidental ASDCoincidental ASD Severe PAHSevere PAH TS or ASTS or AS Very Much Dilated LAVery Much Dilated LA CardiomyopathyCardiomyopathy AF-Loss of Atrial ContractionAF-Loss of Atrial Contraction

MITRAL STENOSIS AND AFMITRAL STENOSIS AND AF

In AF the MS murmur disappears at In AF the MS murmur disappears at the end of a long diastole becausethe end of a long diastole because

1. There is Mild MS-gradient 1. There is Mild MS-gradient disappears.disappears.

2. There is so severe MS-Flow is 2. There is so severe MS-Flow is low.low.

SILENT MSSILENT MSCompletely immobile calcified MVCompletely immobile calcified MVSecond area of stenosis below the Second area of stenosis below the

valvevalvePostero-medially deviated MV Postero-medially deviated MV

orificeorificeLarge ASD (Lutembacher’s Large ASD (Lutembacher’s

SyndromeSyndrome

ETIOLOGYETIOLOGY

1. RHD1. RHD 2. Large LA Myxoma2. Large LA Myxoma 3. Congenital MS: “ Parachute” MV3. Congenital MS: “ Parachute” MV 4. Calcified Bacterial Vegetation.4. Calcified Bacterial Vegetation. 5. Mitral Ring Constriction due to 5. Mitral Ring Constriction due to

localised constrictive pericarditis.localised constrictive pericarditis. 6. Carcinoid Syndrome with PFO/ASD6. Carcinoid Syndrome with PFO/ASD

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISFlow Murmur-Severe MR, VSDFlow Murmur-Severe MR, VSDHypertrophic CardiomyopathyHypertrophic CardiomyopathyNormally functioning porcine valveNormally functioning porcine valveS3 which resembles MSS3 which resembles MSThe Austin-Flint MurmurThe Austin-Flint MurmurCoarctation of AortaCoarctation of Aorta

MITRAL REGURGITATIONMITRAL REGURGITATION

AUSCULTATIONAUSCULTATION

THE FIRST HEART SOUND S1 IN THE FIRST HEART SOUND S1 IN MRMR

Gradient in early and mid-Gradient in early and mid-diastole/MS gradient throughout diastole/MS gradient throughout diastole.diastole.

50% have Soft M150% have Soft M1If LV is not damaged M1 may be If LV is not damaged M1 may be

loudloud70% MR with PMD have Loud S170% MR with PMD have Loud S1

THE SECOND HEART THE SECOND HEART SOUND IN MRSOUND IN MR

Widely Split S2 in MR-Early A2 Due Widely Split S2 in MR-Early A2 Due to Shortened Ejection Time because to Shortened Ejection Time because LV has two outlets.LV has two outlets.But there is also more volume to But there is also more volume to be ejected.be ejected.S2 is not Wide Split in Mild to Mod S2 is not Wide Split in Mild to Mod MRMRLV ejection times are NormalLV ejection times are NormalMR can delay the onset of LV MR can delay the onset of LV Contraction.Contraction.

DIFFERENTIATING S3 FROM DIFFERENTIATING S3 FROM OPENING SNAPOPENING SNAP

OS not more than 100 ms from S2.S3 OS not more than 100 ms from S2.S3 is rarely less than 120 ms from S2.is rarely less than 120 ms from S2.

OS: Short sharp click best heard with OS: Short sharp click best heard with the diaphragm near the LSB. S3 heard the diaphragm near the LSB. S3 heard with the bell near the apex.with the bell near the apex.

OS associated with a Loud S1OS associated with a Loud S1 OS separates further from the A2 OS separates further from the A2

when the patient stands-S3 does not when the patient stands-S3 does not change the distance on standing.change the distance on standing.

EFFECT OF LONG DIASTOLES EFFECT OF LONG DIASTOLES AFAF

HOLOSYSTOLIC: “HOLOS” Greek word HOLOSYSTOLIC: “HOLOS” Greek word meaning “Wholly”, “Complete”, “Entire” and meaning “Wholly”, “Complete”, “Entire” and “all”“all”

PANSYSTOLIC: American from Greek: “Each, PANSYSTOLIC: American from Greek: “Each, “Every”, “all”“Every”, “all”

Murmur Remains Holosystolic during long Murmur Remains Holosystolic during long Diastoles. Diastoles.

Murmur can become softer inMurmur can become softer in 1. MVP MR1. MVP MR 2. PMD MR2. PMD MR Murmur can become louder in Type B WPWMurmur can become louder in Type B WPW

A high- and medium-frequency phonocardiogram taken at the apex together with anexternal carotid tracing from a 45-year-old woman with moderately severe chronicrheumatic MR, with few symptoms on digitalis alone. Because of atrial fibrillation,short and long diastoles are present, demonstrating that the murmur does not growlouder after long diastoles than after short or average diastoles.

CAUSES OF MR MURMUR IN CAUSES OF MR MURMUR IN ADULTSADULTS

RHDRHD MVPMVP PMDPMD RCTRCT LA MYXOMALA MYXOMA CALC MITRAL ANNULUSCALC MITRAL ANNULUS ECD WITH CLEFT AMLECD WITH CLEFT AML ASD WITH MRASD WITH MR HOCMHOCM

CAUSES OF MR MURMUR IN CAUSES OF MR MURMUR IN INFANTSINFANTS

ECDECDALCAPAALCAPASFESFEAcute MyocarditisAcute MyocarditisMyxomatous Degn of MV- Marfan’s Myxomatous Degn of MV- Marfan’s

SyndromeSyndromeEbstein’s Anomaly with CTGVEbstein’s Anomaly with CTGV

SHAPES OF MR MURMURNote that when the MR murmurs begin late, they always go to the second sound, and when they begin early, they always start with the first sound.

PMD CRESCENDO TO PMD CRESCENDO TO S2S2

HOLOSYSTOLIC RHDHOLOSYSTOLIC RHD

ACUTE MR

MVP MR

LOUDEST MR RCT

MVP WITH STANDING

A noncontracting papillary muscle may make its chordae-plus-papillarymuscle relatively longer as the ventricle becomes smaller. This is most likelyto produce a murmur that becomes progressively louder as systole proceeds(crescendo murmur to the S2).

MR MURMUR EXTENDS BEYOND S2

Note that the LV pressure is above leftatrial pressure, even after the A2.

This is a left atrial (wedge) and LV pressure tracing from a 23-year-old woman with ruptured mitral chordae. The shaded area is under the left atrial (wedge) pressure curve. The slight delay in the peak wedge pressure is due to the fact that wedgepressures (taken by a catheter wedged into the distal pulmonaryarterial branches) always show a delay in comparisonwith direct left atrial pressure tracings. The rapid increase inV-wave pressure during systole rapidly decreases the gradient across the mitral valve and will tend to cause both a decrescendo gradient and murmur. The decompressing effecton the LV of the massive loss of blood into the left atriumcauses a late systolic fall in LV pressure. This end-systolicdecrease in LV pressure further decreases the gradient acrossthe mitral valve toward the end of systole.

(A) Excised mitral valve from a patient with myxomatous prolapsed posterior leaflet(PL), who had acute on chronic mitral regurgitation secondary to ruptured chordae. The cliparound it shows the ruptured rough zone chordae of the PL. AL, Anterior leaflet. (B) Phonocardiographic(Phono) recording taken at the apex area from the patient with acute on chronic mitralregurgitation whose excised mitral valve is shown in (A). The regurgitation murmur is followedby a third heart sound (S3).

Simultaneous recordings of electrocardiogram (ECG), apexcardiogram (Apex), and phonocardiogram (Phono) from a patient with ischemic heart disease and papillary muscle dysfunction. The regurgitant murmur is late systolic in timing and appears to peak toward the end of systole.

Phonocardiographic (Phono) recording taken at the apex area from a patient with acute severe mitral regurgitation showing a fourth heart sound (S4) indicating that the left ventricle,which is not very dilated offers resistance to filling.

LOUDNESS SITE RADIATION OF LOUDNESS SITE RADIATION OF MR MURMURMR MURMUR

Slightly Lateral to the Apical Slightly Lateral to the Apical ImpulseImpulse

Radiates to the AxillaRadiates to the AxillaMR Murmur heard at LSB-ECD with MR Murmur heard at LSB-ECD with

Cleft AMLCleft AML

These views of the valve rings from above show how posterior ruptured chordae (on left) can direct the regurgitant stream against the aorta and cause the murmur to be transmitted like an aortic ejection murmur. The diagram at right shows how ruptured anterior chordae can direct the regurgitant stream posteriorly against the spine.

CAUSES OF SILENT SEVERE MRCAUSES OF SILENT SEVERE MR

Concomitant MSConcomitant MSObesityObesityEmphysemaEmphysemaProsthetic Mitral valve due to Prosthetic Mitral valve due to

suture breakdownsuture breakdown

QUANTITATING DEGREE OF MRQUANTITATING DEGREE OF MRTHE MR IS GREATER IFTHE MR IS GREATER IF1.1. Large LV by Palpation.Large LV by Palpation.2.2. Greater and later LPSH (Left Atrial Pulsation)Greater and later LPSH (Left Atrial Pulsation)3.3. Palpable S3Palpable S34.4. Louder and longer the Apical Systolic Murmur.Louder and longer the Apical Systolic Murmur.5.5. More Low and medium fequency murmur More Low and medium fequency murmur High gradient: High Frequency High gradient: High Frequency High Flow: Low frequency –The greater the flow, High Flow: Low frequency –The greater the flow,

the more the low)the more the low)6. Loud S36. Loud S37. Wide Split S27. Wide Split S2

This phonocardiogram and apical pulse tracing is from a 15-year-old girl with severerheumatic MR. The pulse tracing was taken over the LV impulse in the supine positionand is therefore an apex precordiogram instead of an apex cardiogram, which istaken in the left lateral decubitus position. The phonocardiograms are from the thirdleft parasternal interspace. The upper one is taken at medium frequency; the lowerone brings out low and medium frequencies. Note the following signs of severe MR:(1) the widely split S2 of 50 ms; (2) the diastolic flow murmur after the S3; (3) theexaggerated early rapid filling peak of the apical impulse (this would be palpable inthe left lateral decubitus position).

EFFECTS OF DRUGS AND EFFECTS OF DRUGS AND MANEUVERSMANEUVERS

Increasing SVR: MR becomes louderIncreasing SVR: MR becomes louder Diff Long Systolic murmurs due to AS/MRDiff Long Systolic murmurs due to AS/MR With Handgrip, Squatting: With Handgrip, Squatting: AS: No Change AS: No Change MR: LouderMR: Louder Standing: Even though increases SVR does Standing: Even though increases SVR does

not increase MRnot increase MR Decreasing SVR by Amyl Nitrite: Decreases Decreasing SVR by Amyl Nitrite: Decreases

MRMR

MITRAL VALVE MITRAL VALVE PROLAPSEPROLAPSE

AUSCULTATIONAUSCULTATION

(A) Two-dimensional echocardiographic image of the left ventricle (LV), the aorta (AO), and the left atrium (LA) in the parasternal long axis from a patient with redundant myxomatous posterior mitral leaflet scallops with prolapse and mitral regurgitation. Stop frame taken relatively early in systole shows the bulging posterior mitral leaflet (arrow) prolapsing into the LA. (B) Simultaneous recordings of electrocardiogram (ECG), carotid pulse (CP), apexcardiogram (Apex), and phonocardiogram (Phono) from a patient with prolapsed mitral valve syndrome taken from the apex area showing a mid-systolic nonejection click (NEC). (C) Simultaneous recordings of ECG, CP, Apex, and Phono from a patient with prolapsed mitral valve syndrome taken from the apex area showing two clicks (C) in systole.

The midsystolic sound was a click heard loudest at the apex in this 45- year-old woman. The murmur following it is crescendo to the S2. This is the classic ballooned valve click-murmur complex by auscultation.

Simultaneous recordings of ECG, Apex, and Phono from a patient withprolapsed mitral valve syndrome taken from the apex area showing a systolic murmur confined to late systole.

EFFECT OF MANEUVERS ON EFFECT OF MANEUVERS ON THE MVPTHE MVP

Standing, Inspiration and Valsalva: Click and Standing, Inspiration and Valsalva: Click and murmur occur earlier and often louder.murmur occur earlier and often louder.

Click Louder in L.Lat Decubitus.Click Louder in L.Lat Decubitus. BP: Decreases: Click and murmur become softer.BP: Decreases: Click and murmur become softer. Amyl Nitrite: Amyl Nitrite: Immediate:Immediate: Click occurs Click occurs earlier but murmur earlier but murmur becomes softerbecomes softer After 30s: After 30s: BP increases hence itBP increases hence it becomes louderbecomes louder Murmur becomes Murmur becomes

pansystolicpansystolic

DIFF PMD MURMUR FROM MVP DIFF PMD MURMUR FROM MVP MURMUR (Without Click)MURMUR (Without Click)

PMD MURMURPMD MURMURAssociated With S4, Loud S1Associated With S4, Loud S1Softer after long diastoles.Softer after long diastoles. Increase with squatting or Amyl NitriteIncrease with squatting or Amyl Nitrite

MVP MURMURMVP MURMURNo S4 or Loud S1No S4 or Loud S1Become softer with Squatting and Become softer with Squatting and

immediately after Amyl Nitriteimmediately after Amyl Nitrite

OTHER CAUSES OF MID OTHER CAUSES OF MID SYSTOLIC CLICKSSYSTOLIC CLICKS

1.1. Small Left sided pneumothorax.Small Left sided pneumothorax.2.2. Pleural-pericardial adhesions, adhesive pericarditis.Pleural-pericardial adhesions, adhesive pericarditis.3.3. Aneurysm of the Inter-Ventricular Septum. (VSD Closure)Aneurysm of the Inter-Ventricular Septum. (VSD Closure)4.4. Complete absence of the pericardium.Complete absence of the pericardium.5.5. Isolated Bicuspid Pulmonary Valve with RBBBIsolated Bicuspid Pulmonary Valve with RBBB6.6. Severe AR (Traube Pistol Shot Sound).Severe AR (Traube Pistol Shot Sound).7.7. Pacemaker Sound.Pacemaker Sound.8.8. Atrial Myxoma Right or Left.Atrial Myxoma Right or Left.9.9. CHBCHB10.10. Ventricular Aneurysms.Ventricular Aneurysms.11.11. Aneurysm of the Atrial SeptumAneurysm of the Atrial Septum12.12. Swan-Ganz Catheter.Swan-Ganz Catheter.

REFERENCE BOOKSREFERENCE BOOKS Bedside Cardiology: Jules ConstantBedside Cardiology: Jules Constant The Art and Science of Cardiac Physical The Art and Science of Cardiac Physical

Examination N. RanganathanExamination N. Ranganathan Essentials of Bed-Side Cardiology: Essentials of Bed-Side Cardiology:

Jules ConstantJules Constant Clinical Methods in Cardiology: Soma Clinical Methods in Cardiology: Soma

Raju.Raju. Clinical Cardiology: Indranill Basu RayClinical Cardiology: Indranill Basu Ray Cardiology Secrets : O.V. AdairCardiology Secrets : O.V. Adair

THANK YOUTHANK YOU

AORTIC STENOSISAORTIC STENOSIS

AUSCULTATIONAUSCULTATION

THE REVERSED OR THE REVERSED OR PARADOXICALLY SPLIT S2 IN PARADOXICALLY SPLIT S2 IN

ASASThe reversed split in AS implies that The reversed split in AS implies that

the gradient is at least 60 mm hg or the gradient is at least 60 mm hg or moremore

The LV has reched its peak Systolic The LV has reched its peak Systolic pressure of 250 Mm Hg.pressure of 250 Mm Hg.

Subtract the brachial artery systolic Subtract the brachial artery systolic pressure and get the exact gradient pressure and get the exact gradient across the AV.across the AV.

If the split narrows on inspiration, the P2 must come first, and the split S2 is reversed.

HOW TO IDENTIFY THAT THE WIDE HOW TO IDENTIFY THAT THE WIDE SPLIT IS ACTUALLY REVERSEDSPLIT IS ACTUALLY REVERSED

Move Stethoscope from LSB to ApexMove Stethoscope from LSB to Apex Second Component Disappears- A2- P2Second Component Disappears- A2- P2 If First Component becomes soft- P2-A2If First Component becomes soft- P2-A2 Move Stethoscope from Apex to 2 RICSMove Stethoscope from Apex to 2 RICS First Component Heard- A2-P2First Component Heard- A2-P2 Second Component Heard- P2-A2Second Component Heard- P2-A2 Component increasing with inspiration-P2Component increasing with inspiration-P2 During ValsalvaDuring Valsalva P2 Comes early- Split Widens-Reversed SplitP2 Comes early- Split Widens-Reversed Split Normal- Split narrowsNormal- Split narrows During release of Valsalva- Split narrows- P2-A2During release of Valsalva- Split narrows- P2-A2

If the split is fixed at the left sternal border, it may be difficult to tell whether it has a normal or paradoxical sequence. Toward the apex, the componentthat becomes relatively softer must be the P2.

S4 IN ASS4 IN AS In valvular AS it suggests a severe

gradient of at least 70 mmHg across the aortic valve .

This is not valid either in subjects with angina, in whom ischemic heart disease may be an additional causeof an S4.

Subjects with hypertrophic obstructive cardiomyopathy (HOCM), may have an S4 with any gradient.

EJECTION SYSTOLIC MURMUR EJECTION SYSTOLIC MURMUR IN ASIN AS

Mid Systolic is a Poor Term-A regurgitation Mid Systolic is a Poor Term-A regurgitation murmur can also have a Crescendo-murmur can also have a Crescendo-Decrescendo shape and end before A2Decrescendo shape and end before A2

Loudness of the murmurLoudness of the murmur Grade 2 or less: No important gradientGrade 2 or less: No important gradient Grade 4: 20 mmHg gradientGrade 4: 20 mmHg gradient Later the peak and longer- more the stenosisLater the peak and longer- more the stenosis Q-Peak: Less than 200ms- Severe Stenosis (Valve Q-Peak: Less than 200ms- Severe Stenosis (Valve

area Less than 0.75cmarea Less than 0.75cm22 unlikely unlikely Q-Peak: More than 240 ms- Severe StenosisQ-Peak: More than 240 ms- Severe Stenosis Use Doppler point of Maximal VelocityUse Doppler point of Maximal Velocity

A simultaneous aortic and LV pressure tracing (taken with a catheter-tip micromanometer to eliminate time delays through tubes) in a subject with valvular AS. The shape of the murmur follows the shape of the gradient(shaded area).

THE GALLAVARDIN THE GALLAVARDIN PHENOMENONPHENOMENON

The high-frequency components tend to radiate to the apex and may even sound musical at this site suggesting a murmur of MR.

This is called theGallavardin phenomenon, which is especially common in the elderlypatient, in whom the murmur of calcific AS often sounds musical or cooingat the apex.

Commissural fusion is commonly absent in these valves,which allows the cusps to vibrate and produce pure frequencies.

Since aortic ejection murmurs and clicks are often best heard at the apex area, and aortic regurgitation murmurs are usually best heard along the left lower sternal border or midsternum, it should no longer be taught that the “aortic area” is the second right interspace.

A phonocardiogram and simultaneous aortic and LV pressure tracing from a 16-yearold boy with valvular AS. Not only did the murmur and gradient increase after the long diastole, but the ejection sound also increased. Note that the small gradient of the premature ventricular contraction (PVC) itself produced only a short early systolic murmur.

Summary of Auscultatory Clues toSummary of Auscultatory Clues tothe Diagnosis of Severe Aortic Stenosisthe Diagnosis of Severe Aortic Stenosis

The AS is probably severe, i.e., the gradient is at least 70 mm Hg, or in the presenceof congestive heart failure at least 50 mm Hg, if:

1. An S4 is present in a patient under age 40. 2. The murmur is long with its peak in mid-systole, is at

least grade 4/6, and is associated with a soft or absent A2.

3. The S2 has a reversed split provided there is no marked poststenotic dilatation to further delay the A2.

The area of the normally open aortic valve is 3–4 cm2. Symptoms usually do not develop until the area is

reduced to about a third of normal or 1–1.5 cm2, and patients even with this degree of narrowing may remain asymptomatic for decades.

The presence of any of the triad of Angina, Syncope, Dyspnea plus LVH implies a gradient of more thjan 80 mmHg. Unless there is decreased myocardial function

Some are symptom-free with orifices of 0.5 cm2.

AORTIC REGURGITATIONAORTIC REGURGITATION

AUSCULTATIONAUSCULTATION

HEART SOUNDS IN ARHEART SOUNDS IN AR A2 tends to be loud in ARA2 tends to be loud in AR With Severe AR A2 becomes soft.With Severe AR A2 becomes soft. Embryocardia:Embryocardia: When Diastole becomes shorter When Diastole becomes shorter

than Systolethan Systole Adults: Adults: “Tick-Tack” rhythm“Tick-Tack” rhythm Severe AR can produce a Tick-Tack Rhythm Severe AR can produce a Tick-Tack Rhythm

without a tachycardia- increased volume in without a tachycardia- increased volume in Systole can prolong Systole more than Diastole.Systole can prolong Systole more than Diastole.

S3 means LV dysfunctionS3 means LV dysfunction Sudden Severe AR: Sudden Severe AR: Mid-Diastolic S1Mid-Diastolic S1 S4 can occur in Chronic AR (Rheumatic)S4 can occur in Chronic AR (Rheumatic)

DIASTOLIC MURMUR OF ARDIASTOLIC MURMUR OF AR Crescendo-DecrescendoCrescendo-Decrescendo Good Dicrotic Wave- Rebound Effect of the Good Dicrotic Wave- Rebound Effect of the

Aortic leaflets-occurs when AR is mildAortic leaflets-occurs when AR is mild Pandiastolic murmur: AR is at least Pandiastolic murmur: AR is at least

moderate.moderate. Dominant Frequency-HighDominant Frequency-High Moderate AR: Greater flow: Mixed frequencies.Moderate AR: Greater flow: Mixed frequencies. Severe AR: Rough MurmurSevere AR: Rough Murmur

INCREASING LOUDNESS OF AR INCREASING LOUDNESS OF AR MURMURMURMUR

Patient Sit up, lean forward, breath held Patient Sit up, lean forward, breath held in expiration.in expiration.

Increase SVR: Squatting, HandgripIncrease SVR: Squatting, HandgripAR with Soft murmur; Trivial if Diastolic AR with Soft murmur; Trivial if Diastolic

BP more than 70 mm Hg and pulse BP more than 70 mm Hg and pulse pressure is less than 40 mmHgpressure is less than 40 mmHg

Underestimated in presence of MSUnderestimated in presence of MSCombine Squatting and handgrip: Combine Squatting and handgrip:

Squat and Squeeze maneuverSquat and Squeeze maneuver

MUSICAL AR MURMURMUSICAL AR MURMUR Infective EndocarditisInfective EndocarditisEverted leaflets(Luetic)Everted leaflets(Luetic)RSOVRSOVTHE DOVE-COO MUSICAL MURMURTHE DOVE-COO MUSICAL MURMUR Made by the vibrations of the Aorta Made by the vibrations of the Aorta

itselfitself

This murmur was due to mild syphilitic AR. It was loudest at the second and third right interspaces. Note the slight early crescendo–decrescendo. A systolic murmur due to blood going in one direction, together with a diastolic murmur due to bloodgoing in the opposite direction, is called a to-and-fro murmur.

Luetic AR was suspected as the cause of this aortic diastolic murmur. Note the regular vibrations seen in all phonocardiograms of musical murmurs. Dove-Coo Murmur