Systolic Murmurs Dr Muhammed Aslam Junior Resident Pulmonary Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya

Definition of murmur Relatively prolonged series of audible vibrations , Characterized by the timing in cardiac cycle, intensity (loudness), frequency (pitch), quality, configuration, duration and direction of radiation Due to disturbance in blood flow which manifest as turbulence

Description of a Murmur Position in the cardiac cycle , configuration or shape Site of best audibility Intensity length Quality & Pitch Selective Conduction Relation to a physiological act or maneuver

FREEMAN & LEVINE GRADING GRADE 1GRADE 2GRADE 3GRADE 4GRADE 5GRADE 6- faintest murmur which can be heard only with special effort. soft but readily audible loud without thrill loud with thrill heard with steth partially off the chest heard with steth held off the chest wall.

Classification & types of murmurs Systolic murmur early systolic, mid systolic, late systolic, pan/holo systolic Diastolic murmur early diastolic mid diastolic pre systolic Continuous murmur

Systolic Murmurs

Ejection systolic murmur Most common murmur heard in everyday practice. Murmur starting after some time interval from first heart sound and reaching peak by mid-systole or later and ending before the second heart sound of its origin. It could be PATHOLOGICAL or INNOCENT/PHYSIOLOGICAL 1. 2. 3. 4. Ventricular outflow obstruction Dilation of aorta and pulmonary trunk Accelerated systolic flow into aorta or pulmonary trunk Innocent midsystolic murmur( including those due to morphological changes of valve with no obstruction)

Ventricular outflow obstruction

Causes of Left Ventricular Outflow Obstruction Valvular a) Rheumatic b) Congenital- bicuspid and unicuspid valve c)Myxoid dysplasia d)Annular Hypoplasia e)Calcific Degenerative f)Hyper lipidemia g) Fabrys disease h) Infective endocarditis i) Ochronosis

Causes of Left Ventricular Outflow Obstruction Supra Valvular a) Congenital Hour glass type , Diffuse type , Discrete membrane b) Aortic Dissection c) Homozygous type 2 hyperlipidemia d) Healing Aortotomy site e) Rubella

Causes of Left Ventricular Outflow Obstruction Sub valvular a) Dynamic HOCM b) Discrete (Membranous) Sub Aortic Stenosis c) Tunnel Aortic Stenosis

Aortic Stenosis Iso Volumetric Contraction - ventricular pressure increases -opening of Aorta and pulmonary valve- ejection commences and murmur begins Ejection increases -murmur becomes crescendo Ejection declines -murmur in decrescendo Murmur ends before ventricular pressure drops below aortic pressure at which aortic valve and pulmonary valve closes generating a2 and p2

Murmur Of Valvular Aortic Stenosis Site Of Best Audibility Aortic Area -conducted to carotid (best heard with the patient sitting up, leaning forwards and breath held in expiration). Also heard at left sternal border and apex Character- Harsh or rough quality

Site of Best Audibility And Significance in Aortic Stenosis Best audible at right 2nd space , conducted in right carotid Valvular non calcific AS Best audible in left sternal border , no carotid conduction Sub valvular AS , calcific AS , mistaken VSD , mistaken MR Carotid murmur with or without right Supra valvular AS , carotid stenosis second space murmur Audible only at apex Calcific AS in elderly with emphysema , mistaken for MR

Longer the murmur and later in systole the murmur peaks , the more severe the Aortic stenosis , when cardiac out put is within normal limits Severity is over estimated in high cardiac output states and under estimated in low cardiac output states.

Aortic Stenosis At times, as one moves downwards from aortic area to mitral area, the murmur initially becomes softer and then again increases in intensity. This phenomenon is known as 'hourglass conduction'. In calcific aortic stenosis, the murmur is loud and harsh in the aortic area, but it has a musical quality along the left sternal border and at apex. This difference in quality of the same murmur at two different sites is referred to as `Gallavardin phenomenon

Influence Of Various Maneuver In Aortic Stenosis Manaeuver Fixed Obstruction Dynamic Obstruction Respiration No change May with inspiration Standing Valsalva Squatting

HOCM Dynamic LVOT obstruction Murmur will increase in intensity with any manoeuvre that decreases the volume of blood in the left ventricle (such as standing abruptly or the strain phase of a valsalva manoeuvre ) Administration of amyl nitrite will also accentuate the murmur by decreasing venous return to the heart. Classically, the murmur is loudest at the left parasternal edge, 4th intercostal space

Right Ventricular Outflow Obstruction

Causes Valvular Sub Valvular Supra Valvular 1.Congenital Domed,tricuspid,bicuspid ,unicommissural,hypopla stic Annulus,dysplastic 1.Congenital-infundibular Stenosis,double Chambered RV, 1.Congenital 2.Carcinoid Neoplasm Tumor Compression 3.Rheumatic Thrombus Thrombus,rubella

PS Murmur Best audible at left 2nd or 3rd ICS , but is also audible at fourth space along left sternal border. Conducted to supra clavicular area and left side of neck

Site of best audibility / conduction Significance Left second space Valvular PS Infraclavicular and away from midline Supra valvular PS Left 3rd or 4th space Infundibular PS or double chambered RV Right second or third space PS with TGA Conduction to left side of neck Valvular PS Failure of conduction to left side Valvular PS is less likely Ventricular septal diffect is more likely Infundibular PS is likely

Louder ,longer and late peaking murmur is associated with more severe PS . PS murmur is selectively conducted to the infraclavicular region and the left side of neck PS murmur during inspiration and during straining phase of valsalva maneuver

Other causes of MSM Dilation of Aorta & Pulmonary trunk Short soft midsystolic murmur Left sided murmurs in marfans syndrome, syphilis Right sided murmurs in idiopathic dilation of pulmonary artery, pulmonary hypertension MSM of Hyperdynamic circulation Normal aorta or pulmonary trunk but increased flow Anaemia, pregnancy, fever, thyrotoxicosis

Other causes of MSM OS-ASD Rapid flow across pulmonary valve to dilated pulmonary trunk Pure AR Due to Accelerated LV ejection

Physiological causes Innocent systolic murmur Stills murmur Pulmonary mid systolic murmur Peripheral pulmonary systolic murmur Supraclavicular or brachiocephalic systolic murmur Aortic sclerosis Systolic mammary souffl

Pan Systolic/ Holo Systolic Murmur Flow from a chamber or vessel whose pressure or resistance throughout systole is higher than pressure or resistance of the chamber receiving the flow Mitral Regurgitation Tricuspid Regurgitation Ventricular Septal Defect Aorto Pulmonary Window Patent Ductus Arteriosus with PAH

Mitral Regurgitation S1 to S2 provided MV remains incompetent and gradient remains Holosystolic Early systolic Late systolic Sometimes MSM Best audible at apex Radiates to left axilla and back becos jet directed posterolaterally in LA LLSB when jet directed against atrial septum near base of aorta

Mitral Regurgitation Usually 3/6 grade Presence of systolic thrill suggest chordal rupture, IE with vegetations, AS or VSD mistaken as MR Soft and blowing or musical in character

Mitral Regurgitation Relation with various maneuvers Decreases on standing and valsalva Increases with supine

Tricuspid Regurgitation Best audible at tricuspid area (left 4th space) No selective conduction but is often heard to right of sternum Higher the frequency and longer the murmur , more the right ventricle pressure

Tricuspid Regurgitation Rivero Carvallos sign TR murmur increases during inspiration Increased VR increased RV volume Increased SV velocity of regurgitant flow increases Sometimes TR heard only during inspiration Carvallos sign disappears in RV failure

Ventricular Septal Defect Size of VSD is the most important determinant of Auscultatory findings.Other determinants are PAH, Location of defect , and associated defects. Best audible along the left sternal border anywhere from 2nd to 4th spaces and is not selectively conducted to any where. In supracristal VSD murmur is best heard at pulmonary area and may be selectively conducted to the infraclavicular area and the left side of neck

Ventricular Septal Defect Intensity usually above 4/6 grade Rough or Harsh in character Better heard during expiration and is diminished with inspiration Usually appear between 2-6 weeks after birth

Other PSM Aorto Pulmonary Window with PAH Otherwise continuous murmur Diastolic component reduced with increasing PAH PDA with PAH Similar mechanism

Early Systolic Murmurs Begin with the first sound and peak in the first third of systole. Common causes are a small ventricular septal defect (VSD), VSD with PVR or the innocent murmurs of childhood. Other causes are Acute Mitral Regurgitation and Normal pressure TR, Organic TR

LSM MVP Leaflets remains competent during early ventricular contraction but overshoot in late systole One or more mid systolic clicks precede murmur [sudden deceleration of the column of blood against the prolapsed leaflet or scallops] Any maneuver that decreases left ventricular volume such as standing, sitting, Valsalva maneuver ,and amyl nitrate inhalation can produce earlier onset of clicks, longer murmur duration, and decreased murmur intensity. Any maneuver that increases left ventricular volume such as squatting, elevation of legs, hand grip, and phenylephrine can delay the onset of clicks, shorten murmur duration, and increase murmur intensity. Other LSM- papillary muscle dysfunction , Tricuspid valve prolapse