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Dr Muhammed Aslam Junior Resident Pulmonary Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya
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Diastolic Murmurs
Dr Muhammed AslamJunior Resident
Pulmonary MedicineACME 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 valves1.Mid diastolic2.Presystolic3.CombinedB) Those arising at semilunar valves1.Early diastolic2.Mid diastolic sounding early diastolic
Diastolic murmurs at AV valves
Mechanism and Causes of Diastolic Murmurs at Apex
A- Narrowing of mitral valve or left ventricular inflow1.Mitral stenosis2.Left atrial myxoma3.Cor-triatrium4.Constriction of AV groove as in constrictive
pericarditis5.Hypertrophic cardiomyopathy (narrow inflow
cavity
Mechanism and Causes of Diastolic Murmurs at Apex
B.Increased flow across AV valve1.Left to right shunts (post tricuspid shunts)
(VSD,Ductus,systemic artero venous fistula,RSOV in to right ventricle,aotopulmonary window/fistula, Truncus Arteriosus)
2.Mitral Regurgitation (severe)3.Hyperkinetics circulatory
states(anemia,thyrotoxicosis,pregnancy)4.Chronic complete heart block
Mechanism and Causes of Diastolic Murmurs at Apex
C. Mechanisms that interfere with mitral valve openingAustin flint murmur with severe aortic regurgitation
D.Ventricular aneurysm with a narrow neck
E.Murmurs arising some where else but heard at apex1.Aortic regurgitation2.Tricuspid stenosis3. Tricuspid flow murmur of ASD4.Ebstien’s anomaly
Mitral Stenosis murmur featuresFeatures DescriptionSite of best audibility apex
Timing Mid-diastolic/ pre systolic
Selective conduction Localised to apex
character Rough, rumbling (low pitched)
length Short/moderate/long
respiration Increases during expiration
posture >left lateral , < standing
Amyl nitrate inhalation increases
Isotonic exercise increases
Isometric hand grip 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
Mechanism of pre systolic murmur
• Atrial contraction• Persistent atrio ventricular gradient• Left ventricular contraction in presystole
reducing mitral funnel
Absence of presystolic murmur in MS
• Atrial fibrillation• Mild MS• Prolonged PR interval• Bradycardia• Elevated LVEDP (left ventricular
dysfunction)
Severity of MS : Auscultatory features
Severity of ms S2-os interval in second
features
mild 0.08-0.12 Short mdm/ or pre systolic murmur or murmur may appear with exercise
moderate 0.06-0.08 MDM + pre systolic murmur with a gap between them.Varying degree of MDM in atrial fibrillation
sever 0.04-0.06 MDM + pre systolic murmur with no gap.pre systolic murmur with atrial fibrillation
• 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.
Mechanism influencing the length of murmur in MS
1) Cardiac output2) Heart Rate3) Left atrial pressure4) Left ventricular end diastolic pressure5) Heart Rhythm When alteration in any of the above features occur, the
murmur of Mitral stenosis should not be relied upon to assess the severity of mitral 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
Tricuspid diastolic murmursmechanism causesObstruction to rt ventricular inflow •Tricuspid valve stenosis
A-rheumaticB-congenitalC-carcinoid•Right atrial tumors- myxoma/secondary•Ebsteins anomaly
Increased flow across valve Pre tricuspid shuntsA-ASDB-TAPVCC-RSOV TO RAD-LV TO RA communicationsE-coronary artery to RA communicationF-Lutembachers syndromeG-partial anomalous venous connection
Tricuspid diastolic murmursmechanism causes
Interference with opening of TV Severe tricuspid regurgitationA-functionalB-organic
Murmur produced somewhere else but also heard at tricuspid area
•Severe TR with right sided Austin Flint murmur•MS•Pulmonary regurgitation•Aortic regurgitation
Murmurs mistaken for tricuspid diastolic murmur
•Normal pressure pulmonary incompetence•Pericardial rub•Right sided s4 may sound like pre systolic murmur
The murmur of tricuspid stenosisfeatures descriptions
Site of best audibility Tricuspid area
timing Pre systolic with or without Mid diastolic
length Short/moderate/long
character Rough/rumbling
Selective conduction Localised to tricuspid area
Relation to physiological act•Respiration•Posture
•Rapid deep breathing
•Increased during inspiration•Increase in supine , passive leg raising
•increases
• 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) Ebstein’s Anomaly of tricuspid valve
Other mid diastolic murmurs at the AV valve
1) Mid diastolic murmur of MR• Mid diastolic and shorter• Associated with s3• Never pre systolic• Suggest severe MR• Favors rheumatic MR• First sound is usually diminished or absent
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
Causes of Tricuspid flow murmur
A)Left to right shunts(pre tricuspid)1.ASD 2.PAVC3.RSOV4.Coronary cameral fistula in to rt atrium5.Left ventricular right atrial communication
(Gerbodes defect)
Causes of Tricuspid flow murmur
B) Admixture lesions ( Cyanotic heart disease)
1.TAPVC2.Single atrium3.Hypoplastic left heart syndrome ( mitral atresia)C)Severe tricuspid regurgitationsD)The right sided Austin-Flint murmur in
severe functional pulmonary regurgitation
Causes of mitral flow murmurs
A) Left to right shunts (post tricuspid shunts)1.VSD2.PDA3.Aorto pulmonary window4.Systemic arteriovenous fistula
Causes of mitral flow murmurs
B) Admixture lesion (cyanotic heart disease)i) Increased pulmonary flow1.DORV2.SINGLE VENTRICLE3.TRUNCUS ARTERIOSUS4.TRICUSPID ATRESIA WITH LARGE VSD BUT NO PS5.EXTENSIVE BRONCHOPULMONARY COLLATERALS IN PULMONARY
ATRESIA OR ANY CYANOTIC HEART DISEASE WITH DIMINISHED BLOOD FLOW
6.SYSTEMIC TO PULMONARY ARTERY SHUNTS
ii) Diminished pulmonary flowTRICUSPID ATRESIA WITH PULMONIC STENOSIS
Causes of mitral flow murmurs
C. Hyperkinetic circulatory states1.Severe anemia2.Thyrotoxicosis
D. Severe mitral regurgitation
Austin Flint Murmur• In moderate to severe AR• Mid diastolic and/or presystolic• Low pitched best heard with bell• Heavy jet of aortic regurgitation impinging on the
anterior leaflet of mitral valve preventing adequate opening of the valve and creating turbulence to flow from left atrium to ventricle in diastole
• with premature closure of mitral valve as in free severe AR or a/c AR the pre systolic murmur does not occur.
Austin Flint Murmur
• With isometric hand grip, the degree of aortic regurgitation increases due to elevated peripheral vascular resistance and flint murmur increases.
• With administration of vaso dilators , the murmur decreases or disappear due to reduction in severity of AR
Austin Flint vs MSFeatures Austin Flint MS
1.Diastolic Thrill Rare Common
2.Amyl Nitrate Inhalation ↓ ↑
Isometric hand grip / vasopressors
↑ variable
s1 ↓/N ↑
OS - +
LV s3 May occurs never
Rhythm Sinus rhythm AF is common
Auscultatory phenomena simulating mid- diastolic murmurs
1. S3 as MDM2. S4 as presystolic murmur3. S3+s4 together as MDM4. Pericardial knock of constrictive
pericarditis5. Pericardial rub6. The early diastolic murmur of AR at apex
Other Mid Diastolic Murmur
• Carey Coomb’s murmurs
– Acute rheumatic fever, mitral valve structures acutely inflamed with some thickening and edema turbulence of flow during the rapid filling phase + moderate MR [increased mitral inflow in diastole]
– Low pitched short MDM.– Distinguished from MS MDM by the absence of opening snap before
the murmur– good evidence of active carditis
Early diastolic murmur
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. Rheumatic heart disease 2. Congenital bicuspid valve3. IE4. AR in association with valvular
AS or subvalvular fixed AS5. Prosthetic AR
1. Syphilis2. Marfan syndrome3. Ankylosing spondylitis4. Rheumatoid arthritis5. 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 murmur1. a/c AR2. LVF3. Tachycardia4. Hypotension5. Vasodilators6. Pregnancy
Relation to physiological act
• Respiration and posture – best heard in sitting ( or standing ) leaning forward , held in expiration
• Isometric hand grip - ↑• Vasopressor - ↑• Vasodilator - ↓• Squatting - ↑
maneuver mechanisms
Sitting,leaning forward,held expiration,diaphragm firmly applied to chest
•Aorta nearer to chest•Non interference with the noise of breathing•Improved quality of diaphragm to appreciate the high frequency murmur
Prone position Aorta nearer to chest
Prompt squatting Increased systemic vascular resistance
Isometric hand grip As above
vasopressors •Increased systemic resistance
Auscultatory events or murmurs simulating ARAuscultatory event /murmur Differentiating featurePR with PAH (Graham Steel murmur) •Not audible at Rt side of sternum and
apex•May ↑ with inspiration•↓ with standing / inspiration
MDM of severe MS at apex and occasionally along LSB
Low frequency , better heard with bell
MDM of severe MR when heard along left sternal border
As above
MDM of TS •↓ with sitting , standing , during expiration•↑ with inspiration , supine position•Better heard with bell•Prominent a wave with elevated JVP
Pericardial friction rub when high frequency or musical
•Changes with posture / respiration•Never heard to rt of sternum
Cole- Cecil murmur• AR murmur in left axilla due to higher position of apex
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
Relation to physiological act
• Respiration – may incrs during inspiration-mainly in PR with no PAH
• Posture – better heard in supine posture ,passive leg raising
• No influence for isometric hand grip/ vasopressors/amyl nitrite inhalation
PR with normal pressureFeature Description
Timing Mid - diastolic
length Short , never pan diastolic
Site of best audibility Pulmonary area
character Low frequency , rumbling
conduction Localised to pulmonary area , may be heard along left sternal border
Relation to physiological act1. Posture
2. Respiration
• Incrs during supine / passive leg raising .Decrs with standing
• Incrs with inspiration.Decrs with exprn
Other diastolic murmurs
• Cabot– Locke Murmur- [Diastolic Flow murmur] - in severe anemia
– The Cabot–Locke murmur is a diastolic murmur that sounds similar to aortic insufficiency but does not have a decrescendo; it is heard best at the left sternal border. [High flow thru coronary vessels, LMCA, LAD]
– The murmur resolves with treatment of anaemia.
• Dock’s 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
Other diastolic murmurs
• Key–Hodgkin murmur – EDM of AR; it has a raspy quality, [sound of a saw cutting through
wood]. Hodgkin correlated the murmur with retroversion of the aortic valve leaflets in syphilitic disease.
• Rytand’s murmur– Late diastolic murmur in complete heart block
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