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Systolic Ejection MurmursChapter 14
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS
Outline
• Outflow Tracts• Inflow Tracts• Inter-Ventricular Flow• Ejection Murmur• Classification of
Ejection• Aortic Stenosis• Bicuspid Aortic Valve
• Tetralogy of Fallot• Dilatation of the
Proximal Pulmonary• Pulmonary Arterial
Narrowing• Coarctation of the
Aorta• Musical Murmurs
Introduction
• Levine stated, “Systolic noise with a duration longer than a heart sound.”
• Result of turbulent blood flow across outflow tracts, ejection murmurs,inflow tract, and from ventricle to ventricle
Outflow Tracts/ Ejection Pathways
• Left outflow tract– Left ventricle– Aortic valve– Aortic root– Ascending Aorta
• Right outflow tract– Right ventricle– Pulmonary Valve– Main Pulmonary
Artery
Causes of Abnormalities of Flow
• Forward flow across normal outflow tracts• Forward flow across stenosed aortic or
pulmonic outflow tracts• High flow across normal right or left
ventricular outflow tracts• High flow across a regurgitant aortic or
pulmonic valve without significant stenosis• Forward flow into a dilated great vessel
Inflow Tracts
• The inflow tracts of the heart are the chambers that are open to tack other during diastolic filling. – Mitral valve is part of the left inflow tract– Tricuspid valve is part of the right inflow tract
• Abnormalities are insufficiency/regurgitant related: rheumatic valvular disease, mitral valve prolapse, or papillary muscle dysfunction
Inter-Ventricular Flow
• Small VSD results in turbulent blood flow from ventricular to ventricle
Ejection Murmur
• Mixed frequencies and is moderate-to-marked crescendo-decrescendo
• Caused by forward flow across the left or right outflow
• Aortic stenosis & pulmonic stenosis
Classification of Ejection Murmurs• Early Systolic Ejection Murmur
– Commonly heard in a small VSD without pulmonary hypertension, large VSD with pulmonary hypertension, septal perforation resulting from MI, acute severe mitral regurgitation
• Mid-systolic Ejection Murmur– Long and is loudest in mid-systolic with the sound of S2
clearly audible & implies significant aortic or pulmonic outflow tract obstruction, TOF, dilatation of he proximal pulmonary artery or ASD
Aortic Stenosis• Murmur is harsh, rough, & grunting• Degrees of Obstruction
– Mild- softer, shorter & earlier-peaking systolic murmur– Severe-louder, longer, & late-peaking murmur
• Causes– Result of congenital aortic valve disease, rheumatic fever
(aortic & mitral valve involved), or degenerative calcification in elderly patients
• Listen with the diaphragm of the stethoscope for maximal intensity at the second right intercostal space; listen at the apex & over the precordium, both clavicles, both carotids, & suprasternal notch
Pulmonic Valve Stenosis• Harsh systolic murmur,wide splitting of S2
• Loudest in the 2nd & 3rd interspaces along the left sternal border (pulmonic area)
• Palpable Thrill felt directed toward the left neck or clavicle
• Murmur peaks in mid-systole with maximal ejection & produces a diamond shape on the phono.
• Heard during expiration• Ejection sound heard over the pulmonary area• Sound caused by doming & abrupt arrest in motion of
the stenotic PV
Tetralogy of Fallot
• Described by Fallot in 1888• VSD, Pulmonic Stenosis, Dextroposition of the
aorta & RV hypertrophy• PS results of a fibromuscular ring below the PV in
the RV out flow tract-infundibular • More severe the obstruction, the more blood is
shunted RT to LT the VSD• Systolic thrill pulmonic with grade IV murmur
Coarctation of the Aorta
• Grade II or III murmur
• Heard posteriorly & over base of the heart
• Hypertension in the arms, but not in the legs
• Decreased or absent femoral arterial pulsation
Musical Murmurs• Caused by vibrating structure enve in the the absence of
flow turbulence• Musical systolic murmurs
– Cooing of a dove
– Buzzing of a saw
– Spinning of a top
– Whistling
– Systolic whoop
– Precordial honk
• Mitral valve prolapse can assume such a noise
THE END OF
CHAPTER 14
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp. 154-178