Professional Documents
Culture Documents
Dr Muhammed Aslam Junior Resident Pulmonary Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya
Diastolic Murmurs
Always signify an abnormal cvs structurally or functionally Not graded by intensity but by their length Thrill additionally mentioned
Classification
A) Those arising at the AV valves 1.Mid diastolic 2.Presystolic 3.Combined B) Those arising at semilunar valves 1.Early diastolic 2.Mid diastolic sounding early diastolic
1.Aortic regurgitation 2.Tricuspid stenosis 3. Tricuspid flow murmur of ASD 4.Ebstiens anomaly
increases variable
Mechanism of MDM in MS
As the mitral valve become stenotic the left atrial pressure increases with a gradient between left atrium and left ventricle in diastole. The opening snap result from abrupt opening of the doming mitrale valve. As the atrial contraction contributes to increased gradient in pre systole, there is pre systolic accentuation of murmur
moderate
0.06-0.08
MDM + pre systolic murmur with a gap between them. Varying degree of MDM in atrial fibrillation
MDM + pre systolic murmur with no gap.pre systolic murmur with atrial fibrillation
sever
0.04-0.06
With a HR 70-90/min a normal cardiac out put and a normal left ventricular end diastolic pressures , the longer murmur the more severe the stenosis.
Character of murmur
Rough, rumbling (low pitched) Non calcific valve Very low frequency, loud diastolic murmur with a thrill Severe calcific valve high frequency, less intensity , no thrill Heard with bell of diaphragm
length
Short/moderate/long
character
Selective conduction Relation to physiological act Respiration Posture Rapid deep breathing
Rough/rumbling
Localised to tricuspid area
Length of murmur is directly related to the severity of tricuspid stenosis Significant tricuspid stenosis with shorter or no murmur : causes
1)Rheumatic TS with accompanying MS, severe PAH ,Increased Right ventricular end diastolic pressure 2) Diuretic therapy in TS 3) Atrial fibrillation ( absent pre systolic murmur) 4) Ebsteins Anomaly of tricuspid valve
2.MDM of L to R shunt
Tricuspid flow murmur in ASD
Best heard at lower left sternal border but may be heard at apex or upper left sternal border Only mid diastolic with no presystolic murmur Relatively soft or medium frequency No significant change with respiration Indicate pulmonary flow to be twice the systemic flow or higher
C)Severe tricuspid regurgitations D)The right sided Austin-Flint murmur in severe functional pulmonary regurgitation
Austin Flint vs MS
Features Austin Flint MS
1.Diastolic Thrill
2.Amyl Nitrate Inhalation
Rare
Common
variable
+ never AF is common
AR murmur
Timing - Early diastolic Site of best audibility best heard along left sternal border, but is also well heard at right 2nd space and apex.
Left sternal border murmur of AR causes Right sternal border murmur of AR causes
1. 2. 3. 4.
Rheumatic heart disease Congenital bicuspid valve IE AR in association with valvular AS or subvalvular fixed AS 5. Prosthetic AR
1. 2. 3. 4. 5.
Syphilis Marfan syndrome Ankylosing spondylitis Rheumatoid arthritis AR associated with TOF or VSD
AR murmur
Character- high frequency / soft / blowing/ musical Thrill is rare Length of the murmur correlates with severity
AR murmur
Causes of AR with short or no murmur 1. a/c AR 2. LVF 3. Tachycardia 4. Hypotension 5. Vasodilators 6. Pregnancy
mechanisms Aorta nearer to chest Non interference with the noise of breathing Improved quality of diaphragm to appreciate the high frequency murmur
MDM of severe MS at apex and occasionally along LSB MDM of severe MR when heard along left sternal border MDM of TS
Murmur of Pulmonary Regurgitation with PAH (Graham Steell murmur) Timing early diastolic Length- very short to pan diastolic Length of murmur reflects the duration of pressure difference between pulmonary artery and right ventricle in diastole
Site of best audibility pulmonary area Character high pitched (PR with no PAH is low frequency ) Conduction left sternal border 3 rd and 4 th spaces
length
Pulmonary area
character
conduction
Incrs during supine / passive leg raising .Decrs with standing Incrs with inspiration.Decrs with exprn
Docks murmur
diastolic crescendo-decrescendo, with late accentuation, [consistent with blood flow through the coronary] in a sharply localized area, 4 cm left of the sternum in the 3LICS, detectable only when the patient was sitting upright. Due to stenosis of LAD
Rytands murmur
Late diastolic murmur in complete heart block