Regurgitant Systolic MurmursChapter 15

Are G. Talking, MD, FACC

Instructor

Patricia L. Thomas, MBA, RCIS

Outline

• Mitral Regurgitation

• Tricuspid Regurgitation

• Ventricular Septal Defect

• Patent Ductus Arterious

• Acute Ventricular Septal Perforation

• Papillary Muscle Rupture

• Mitral Valve Prolapse Syndrome

Introduction

• Regurgitant Murmurs are caused by retrograde flow across AV valves

• TR heard at the lower left sternal border

• MR heard at the apex

• Holosystolic Murmurs suggest MR, TR, VSD’s

Chronic Mitral Regurgitation

• Continues as long as LV pressure > that of the enlarged LA

• Begins at S1 and extend through S2

• Large high pitched, blowing holosystolic/pansystolic murmur

Acute Mitral Regurgitation

• Loud Grade IV or >, diamond shaped

• Pressure in the normal nondilated LA increases rapidly because of regurgitant flow in early systole and = LV pressure in late systole

Mitral Regurgitation Causes

• Rheumatic Heart Disease

• Papillary Muscle Dysfunction

• Mitral Valve Prolapse

• Rupture Chordae Tendineae

• Calcified mitral Annulus

• LV Dilatation

Tricuspid Regurgitation

• The holosystolic murmur of MR engulfs A2 but stops before P2 whereas the murmur of TR persists through and engulfs P2

• Increases with inspiration (Carvallo sign) & does not radiate well to the axillary region

• Mild TR– Infective Endocarditis

seen with IV drug abuse may be mid-systolic of low intensity, heart only with inspiration

– S4 may be present

• Advance TR– May not increase with

inspiration or may be absent

– Tricuspid honk or whoop (highly musical)

Causes• Tricuspid Insufficiency is commonly secondary to

dilatation of the right ventricle • Severe Right Heart Failure secondary to mitral

stenosis• Pulmonary Heart Disease with pulmonary

hypertension• Congenital deformity (Epstein's Anomaly),

Rheumatic Valve disease, or Infective Endocarditis

• Listen with the diaphragm of the stethoscope along the lower left sternal border (third interspace)

Ventricular Septal Defect

• Holosystolic, loud, & harsh; S2 is loud & widely split; possible palpable thrill

• Begins with ventricular systole S1, when the rise in LV pressure exceeds that of the RV & continues until S2 when left ventricular pressure falls

• Listen with the diaphragm of the stethoscope from the mid-to lower left sternal border

• Patent Ductus Arteriosus– Continuous murmur

• Acute Ventricular Septal Perforation– Caused by acute MI– Loud short systolic murmur, grade IV– Listen with diaphragm of stethoscope

• Papillary Muscle Rupture– mid-to late systolic murmur, thrill– Listen with diaphragm for the stethoscope

Mitral Valve Prolapse Syndrome• Mid-to-late systolic, late systolic, or holosystolic• Moderate Prolapse

– 1/3 or ½ into systole & increases its intensity until A2

– Valve is competent in early systole & prolapse in LA in late systole

• Severe Prolapse– Loud S1, holosystolic murmur– Fusion of a click with S1, Sound is louder

• Click – In < ½ of patients marks onset of the murmur “click

murmur syndrome”

• Cause– Mitral insufficiency

THE ENDOF

CHAPTER 15

Tilkian, Ara MD Understanding Heart Sounds and Murmurs,

Fourth Edition, W.B. Sunders Company. 2002, pp. 180-196