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Mid-systolic ejection

Time Condition Description

Mid-systolic

ejection

Aortic outflowobstruction

(Aortic Stenosis)

Can be due to aortic valve stenosis orhypertrophiccardiomyopathy(HCM), with a harsh and rough quality.

**Valvular aortic stenosiscan produce a harsh, or even amusical murmur over the right second intercostal space whichradiates into the neck over the two carotid arteries. The most

common cause of AS (Aortic Stenosis) is calcified valves due to

aging. The second most common cause is congenital bicuspid

aortic valves (normal valve is tricuspid). In aortic stenosis,heaving apical impulse is present. The distinguishing feature

between these two causes is that bicuspid AS has little or no

radiation. It can be confirmed if it also has an aortic ejection

sound, a short early diastolic murmur, and normal carotid pulse.The murmur in valvular AS decreases with standing and

straining with Valsalva maneuver.** Supravalvular aortic stenosis is loudest at a point slightlyhigher than in that of valvular AS and may radiate more to the

right carotid artery.

**Subvalvular aortic stenosisis usually due to hypertrophiccardiomyopathy (HCM), with murmur loudest over the left

sternal border or the apex. The murmur in HCM increases in

intensity with a standing position as well as straining with

Valsalva maneuver.

Mid-

systolic

ejection

Pulmonic

outflow

obstruction(Pulmonic

Stenosis)

A harsh murmur usually on left second intercostal space

radiating to left neck and accompanied by palpable thrill. It can

be distinguished from a VSD (Ventricular septal defect) bylistening to the S2, which is normal in VSD but it is widely split

in pulmonary stenosis. However, VSD is almost alwayspansystolic where the murmur of pulmonary stenosis is

diamond-shaped and ends clearly before S2. Many innocent

murmurs also arise from this location but S1 and S2 must splitnormally.

Mid-systolic

ejection

Dilation of aorticroot or

pulmonary artery

Produces an ejection sound, with a short ejection systolicmurmur and a relatively wide split S2. There is no hemodynamic

abnormality. This is similar to pulmonary hypertension except

the latter has hemodynamic instabilities.

Mid-systolicejection

Increasedsemilunar bloodflow

This can occur in situations such asanemia,pregnancy, orhyperthyroidism.

Mid-systolic

ejection

Aortic valvesclerosis

This is due to degenerative thickening of the roots of the aorticcusps but produces no obstruction and no hemodynamic

instability and thus should be differentiated from aortic stenosis.

It is heard over right second intercostal space with a normal

carotid pulse and normal S2.

http://en.wikipedia.org/wiki/Aortic_Stenosishttp://en.wikipedia.org/wiki/Aortic_Stenosishttp://en.wikipedia.org/wiki/Aortic_Stenosishttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathyhttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathyhttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathyhttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathyhttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Aortic_valve_stenosishttp://en.wikipedia.org/wiki/Aortic_valve_stenosishttp://en.wikipedia.org/wiki/Aortic_valve_stenosishttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy#Dynamic_outflow_obstructionhttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy#Dynamic_outflow_obstructionhttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy#Dynamic_outflow_obstructionhttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonic_Stenosishttp://en.wikipedia.org/wiki/Pulmonic_Stenosishttp://en.wikipedia.org/wiki/Pulmonic_Stenosishttp://en.wikipedia.org/wiki/Pulmonic_Stenosishttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Hyperthyroidismhttp://en.wikipedia.org/wiki/Hyperthyroidismhttp://en.wikipedia.org/wiki/Hyperthyroidismhttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Pulmonic_Stenosishttp://en.wikipedia.org/wiki/Pulmonic_Stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy#Dynamic_outflow_obstructionhttp://en.wikipedia.org/wiki/Aortic_valve_stenosishttp://en.wikipedia.org/wiki/Pulmonary_valve_stenosishttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathyhttp://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathyhttp://en.wikipedia.org/wiki/Aortic_Stenosis

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Mid-

systolicejection

Innocent

midsystolicmurmurs

These murmurs are not accompanied by other abnormal findings.

One example of abenign paediatric heart murmurisStill'smurmurin children.

Late systolic

Time is

important

Condition Description

Late

systolic

Mitral valve

prolapse

This is the most common cause of late systolic murmurs. It can

be heard best over the apex of the heart, usually preceded byclicks. The most common cause of mitral valve prolapse is

"floppy" valve (Barlow's) syndrome. If the prolapse becomes

severe enough, mitral regurgitation may occur. 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 ventricularvolumesuch as squatting, elevation of legs, hand grip, andphenylephrinecan delay the onset of clicks, shorten murmur

duration, and increase murmur intensity.

Late

systolic

Tricuspid

valve prolapse

Uncommon without concomitant mitral valve prolapse. Best

heard over left lower sternal border.

Late

systolic

Papillary

muscledysfunction

Usually due to acute myocardial infarction or ischemia, which

causes mild mitral regurgitation.

Holosystolic (pansystolic)

Time Condition Description

Holosystolic

(pansystolic)

Tricuspid

insufficiency

Intensifies upon inspiration. Can be best heard over the fourth

left sternal border. The intensity can be accentuated following

inspiration (Carvallo's sign) due to increased regurgitant flow

in right ventricular volume. Tricuspid regurgitation is mostoften secondary topulmonary hypertension. Primary tricuspid

regurgitation is less common and can be due to bacterial

endocarditisfollowingIV drug use,Ebstein's anomaly,

carcinoid disease, or prior right ventricular infarction.

Holosystolic

(pansystolic)

Mitral

regurgitationNo intensification upon inspiration. In the presence of

incompetent mitral valve, the pressure in the L ventriclebecomes greater than that in the L atrium at the onset of

isovolumic contraction, which corresponds to the closing of

the mitral valve (S1). This explains why the murmur in MRstarts at the same time as S1. This difference in pressure

extends throughout systole and can even continue after the

aortic valve has closed, explaining how it can sometimesdrown the sound of S2. The murmur in MR is high pitched and

http://en.wikipedia.org/wiki/Benign_paediatric_heart_murmurhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmurhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmurhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur#Types.2C_description_and_DDxhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur#Types.2C_description_and_DDxhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur#Types.2C_description_and_DDxhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur#Types.2C_description_and_DDxhttp://en.wikipedia.org/wiki/Mitral_valve_prolapsehttp://en.wikipedia.org/wiki/Mitral_valve_prolapsehttp://en.wikipedia.org/wiki/Mitral_valve_prolapsehttp://en.wikipedia.org/wiki/Valsalva_maneuverhttp://en.wikipedia.org/wiki/Valsalva_maneuverhttp://en.wikipedia.org/wiki/Tricuspid_insufficiencyhttp://en.wikipedia.org/wiki/Tricuspid_insufficiencyhttp://en.wikipedia.org/wiki/Carvallo%27s_signhttp://en.wikipedia.org/wiki/Carvallo%27s_signhttp://en.wikipedia.org/wiki/Carvallo%27s_signhttp://en.wikipedia.org/wiki/Pulmonary_hypertensionhttp://en.wikipedia.org/wiki/Pulmonary_hypertensionhttp://en.wikipedia.org/wiki/Pulmonary_hypertensionhttp://en.wikipedia.org/wiki/Endocarditishttp://en.wikipedia.org/wiki/Endocarditishttp://en.wikipedia.org/wiki/IV_drug_usehttp://en.wikipedia.org/wiki/IV_drug_usehttp://en.wikipedia.org/wiki/IV_drug_usehttp://en.wikipedia.org/wiki/Ebstein%27s_anomalyhttp://en.wikipedia.org/wiki/Ebstein%27s_anomalyhttp://en.wikipedia.org/wiki/Ebstein%27s_anomalyhttp://en.wikipedia.org/w/index.php?title=Carcinoid_disease&action=edit&redlink=1http://en.wikipedia.org/w/index.php?title=Carcinoid_disease&action=edit&redlink=1http://en.wikipedia.org/wiki/Mitral_regurgitationhttp://en.wikipedia.org/wiki/Mitral_regurgitationhttp://en.wikipedia.org/wiki/Mitral_regurgitationhttp://en.wikipedia.org/wiki/Mitral_regurgitationhttp://en.wikipedia.org/wiki/Mitral_regurgitationhttp://en.wikipedia.org/w/index.php?title=Carcinoid_disease&action=edit&redlink=1http://en.wikipedia.org/wiki/Ebstein%27s_anomalyhttp://en.wikipedia.org/wiki/IV_drug_usehttp://en.wikipedia.org/wiki/Endocarditishttp://en.wikipedia.org/wiki/Pulmonary_hypertensionhttp://en.wikipedia.org/wiki/Carvallo%27s_signhttp://en.wikipedia.org/wiki/Tricuspid_insufficiencyhttp://en.wikipedia.org/wiki/Tricuspid_insufficiencyhttp://en.wikipedia.org/wiki/Valsalva_maneuverhttp://en.wikipedia.org/wiki/Mitral_valve_prolapsehttp://en.wikipedia.org/wiki/Mitral_valve_prolapsehttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur#Types.2C_description_and_DDxhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur#Types.2C_description_and_DDxhttp://en.wikipedia.org/wiki/Benign_paediatric_heart_murmur

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best heard at the apex with diaphragm of the stethoscope with

patient in the lateral decubitus position. Left ventricularfunction can be assessed by determining the apical impulse. A

normal or hyperdynamic apical impulse suggests good ejection

fraction and primary MR. A displaced and sustained apical

impulse suggests decreased ejection fraction and chronic andsevere MR.

Holosystolic

(pansystolic)

Ventricular

septal defect

No intensification upon inspiration. VSD is a defect in the

ventricular wall, producing a shunt between the left and right

ventricles. Since the L ventricle has a higher pressure than theR ventricle, flow during systole occurs from the L to R

ventricle, producing the holosystolic murmur. It can be best

heard over the left third and fourth intercostal spaces and along

the sternal border. It is associated with normal pulmonaryartery pressure and thus S2 is normal. This fact can be used to

distinguish from pulmonary stenosis, which has a wide

splitting S2. When the shunt becomes reversed ("Eisenmengersyndrome"), the murmur may be absent and S2 can becomemarkedly accentuated and single.

http://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Eisenmenger_syndromehttp://en.wikipedia.org/wiki/Eisenmenger_syndromehttp://en.wikipedia.org/wiki/Eisenmenger_syndromehttp://en.wikipedia.org/wiki/Eisenmenger_syndromehttp://en.wikipedia.org/wiki/Eisenmenger_syndromehttp://en.wikipedia.org/wiki/Eisenmenger_syndromehttp://en.wikipedia.org/wiki/Ventricular_septal_defecthttp://en.wikipedia.org/wiki/Ventricular_septal_defect