Dynamic Auscultation

Listening to the change in character, behaviour and the intensity of the heart sounds and murmurs to physiological and pharmacological maneuvers…….

“AUSCULTATE WITH ALTERED HEMODYNAMICS”

Dynamic Auscultation

• Source of murmur : Right Heart ~ Left Heart• Differentiate closely simulating murmurs Outflow ~ Regurgitatnt murmur• Differentiate flow murmurs from those of

structural deformity : Austin Flint ~ MS• Differentiate Dynamic from Fixed Obstructions

Maneuvres PHYSI(OLOGI)CAL• Postural change Supine / L Lateral Standing Squatting• Valsalva• Handgrip• Cycle length change

PHARMACOLOGICAL• Amyl nitrite• Phenylephrine

Position

• Left lateral decubitus : Augments the murmur of MS, MR, Austin Flint, MVP & S1, LV S3 & S4

• Sitting & Leaning forward : ↑ AR murmur• Sitting with arms raised above the head : ↑ AR• Knee chest position : AR, Pericardial Rub• Passive leg raising : ↑ VR >↑ Right Heart events

Respiration• Inspiration augments right sided events, as the

venous return increases : TR & TS , PR & PS murmurs ; RV S3,S4 & TV OS S1 & S2 split widen.• Exception is PES – augmented in expiration # Preferably quiet respiration # Avoid apnea # Listen the first few beats # In erect posture if Venous pressure is high

Carvallo’s sign• Inspiratory accentuation of TR murmur• Early systolic murmur > holosystolic• Blowing quality > musical• Absent in severe RV failure associated TS is severe• If venous pressure is very high,

listening in upright posture may help

Reversed Carvallo sign HCM with RVO obstruction - ? ↑ VR > widened RVO

Respiration• Left sided events are better heard in expiration MR, MS, AS & AR murmurs LV S3 & S4, Mitral OS Click & murmur of MVP occur later @ PV – LA gradient increases > ↑ LV filling @ Lung overlap decreases @ Apnea for faint AR murmur

Pms = mean systemic pressure; Ppc = pulmonary capillary hydrostatic pressure; Ppi = pulmonary interstitial hydrostatic pressure; Ptm = pulmonary capillary transmural pressure

Abrupt standing• S2 split which may be wide, may narrow down ,

while the fixed split may persist• A2 OS interval widens – differentiates from

wide split of S2• All murmurs ( except MVP/HOCM) decrease• ESM of HOCM becomes louder and longer• Click occurs earlier, murmur becomes longer in

MVP – loudness shows variable response

Isometric Hand Grip

HAND DYNAMOMETER

Physiological changes of

ISOMETRIC HANDGRIP EXERCISE

Isometric Hand Grip

LV S3 & S4 get augmentedMurmurs of MR,AR,VSD intensifyMitral stenotic murmur may augmentSystolic murmur of HOCM may diminishClick & late sytolic murmur of MVP get delayed

Transient Arterial Occlusion

Squatting• Increased venous return and CO >

augments most murmurs atleast initially (AS,PS,MR,AR,VSD) Right heart murmurs do so earlier

• Increased ventricular volume > murmur of HOCM ↓ murmur of MVP ↓→

• Ejection murmur of TOF ↑

P Hanson Br HeartJ7 1995;74:154

Central Aortic Pressure

T Murakami AHJ 2002; 15:986–988

Hemodynamics of Squatting T Murakami AHJ 2002; 15:986–988

T Murakami AHJ 2002; 15:986–988

Valsalva Maneuver

Decreased venous return & CO, HR ↑; PP↓ S2 split narrows down, S3 & S4 diminish

Valsalva Maneuver• Reduces the intensity of all murmurs

except that of HOCM & MVP • Murmur of HOCM intensifies as the LV

cavity size decreases• Click occurs earlier, the murmur lengthens

in MVP – may not intensify• During release, the intensity of right heart

murmurs returns earlier - 1 to 3 vs 5 beats for left heart murmurs

VALSALVA STRAIN

ASD, HF, MS

Cycle Length VariationPost premature beat / Long cycle short cycle of AF

• Post VPD / Long > Short cycle of AF : Outflow murmurs ( AS/PS) accentuate Regurgitant murmurs do not change

Aortic Stenosis HOCM

Amylnitrite Inhalation < 30 secs : Systemic vasodilatation 30 – 60 secs : ↑ HR & CO Augments S1, LV S3 & S4, TV & MV OS,

murmurs of AS,PS,TR & HOCM A2 – OS may widen Diminishes the murmurs of MR, AR, VSD, PDA

& Systemic AVF Click & Murmur of MVP occur earlier

Amyl Nitrite Inhalation

Augments Diminishes• Aortic stenosis Mitral regurgitation• Pulmonary stenosis TOF• Tricuspid regurgitation Mitral regurgitation• Mitral stenosis Austin Flint• Pulmonary regurgitation Aortic Regurgitaation

Phenylephrine↑ BP & SVR ↓ CO & HR – last for 3-5mts• Reduces intensity of S1, A2-OS may widen• Augments the murmurs of VSD, PDA, MR, AR,

TOF, Systemic AVF• Diminishes AS, MS & functional murmurs• ESM of HOCM diminishes• Click & murmur of MVP get delayed

↑Afterload,↑Preload,↓Contractility

↓Afterload,↓Preload,↑Contractility

Valslava

the caveats are………• Avoid dynamic auscultation in sick patients • When postures are changed, transition should

be abrupt • Continuous auscultation is required, when

maneuvres are being elicited• Concentrate on the first few cycles after

maneuvres• Realize that each maneuvre induces more

than one alterations in hemodynamics