Diastolic murmurs

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

1. Diastolic Murmurs Dr Muhammed Aslam Junior Resident Pulmonary Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya

2. Diastolic Murmurs Always signify an abnormal cvs - structurally or functionally Not graded by intensity but by their length Thrill additionally mentioned

3. 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

4. Diastolic murmurs at AV valves

5. Mechanism and Causes of Diastolic Murmurs at Apex A- Narrowing of mitral valve or left ventricular inflow 1.Mitral stenosis 2.Left atrial myxoma 3.Cor-triatrium 4.Constriction of AV groove as in constrictive pericarditis 5.Hypertrophic cardiomyopathy (narrow inflow cavity

6. Mechanism and Causes of Diastolic Murmurs at Apex B.Increased flow across AV valve 1.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

7. Mechanism and Causes of Diastolic Murmurs at Apex C. Mechanisms that interfere with mitral valve opening Austin flint murmur with severe aortic regurgitation D.Ventricular aneurysm with a narrow neck E.Murmurs arising some where else but heard at apex 1.Aortic regurgitation 2.Tricuspid stenosis 3. Tricuspid flow murmur of ASD 4.Ebstien’s anomaly

8. Mitral Stenosis murmur features Features Description Site 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

9. 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

10. Mechanism of pre systolic murmur Atrial contraction Persistent atrio ventricular gradient Left ventricular contraction in presystole reducing mitral funnel

11. Absence of presystolic murmur in MS Atrial fibrillation Mild MS Prolonged PR interval Bradycardia Elevated LVEDP (left ventricular dysfunction)

12. 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

13. 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 .

14. Mechanism influencing the length of murmur in MS Cardiac output Heart Rate Left atrial pressure Left ventricular end diastolic pressure 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

15. 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

16. Tricuspid diastolic murmurs mechanism causes Obstruction to rt ventricular inflow Tricuspid valve stenosis A-rheumatic B-congenital C- carcinoid Right atrial tumors- myxoma /secondary Ebsteins anomaly Increased flow across valve Pre tricuspid shunts A-ASD B-TAPVC C-RSOV TO RA D-LV TO RA communications E-coronary artery to RA communication F- Lutembachers syndrome G-partial anomalous venous connection

17. Tricuspid diastolic murmurs mechanism causes Interference with opening of TV Severe tricuspid regurgitation A-functional B-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

18. The murmur of tricuspid stenosis features 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

19. 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

20. Other mid diastolic murmurs at the AV valve 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

21. 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

22. Causes of Tricuspid flow murmur A)Left to right shunts(pre tricuspid) 1.ASD 2.PAVC 3.RSOV 4.Coronary cameral fistula in to rt atrium 5.Left ventricular right atrial communication ( Gerbodes defect)

23. Causes of Tricuspid flow murmur B) Admixture lesions ( Cyanotic heart disease) 1.TAPVC 2.Single atrium 3.Hypoplastic left heart syndrome ( mitral atresia ) C)Severe tricuspid regurgitations D)The right sided Austin-Flint murmur in severe functional pulmonary regurgitation

24. Causes of mitral flow murmurs Left to right shunts (post tricuspid shunts) 1.VSD 2.PDA 3.Aorto pulmonary window 4.Systemic arteriovenous fistula

25. Causes of mitral flow murmurs B) Admixture lesion (cyanotic heart disease) Increased pulmonary flow 1.DORV 2.SINGLE VENTRICLE 3.TRUNCUS ARTERIOSUS 4.TRICUSPID ATRESIA WITH LARGE VSD BUT NO PS 5.EXTENSIVE BRONCHOPULMONARY COLLATERALS IN PULMONARY ATRESIA OR ANY CYANOTIC HEART DISEASE WITH DIMINISHED BLOOD FLOW 6.SYSTEMIC TO PULMONARY ARTERY SHUNTS ii) Diminished pulmonary flow TRICUSPID ATRESIA WITH PULMONIC STENOSIS

26. Causes of mitral flow murmurs C. Hyperkinetic circulatory states 1.Severe anemia 2.Thyrotoxicosis D. Severe mitral regurgitation

27. 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.

28. 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

29. Austin Flint vs MS Features 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

30. Auscultatory phenomena simulating mid- diastolic murmurs S3 as MDM S4 as presystolic murmur S3+s4 together as MDM Pericardial knock of constrictive pericarditis Pericardial rub The early diastolic murmur of AR at apex

31. 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

32. Early diastolic murmur

33. AR murmur Timing - Early diastolic Site of best audibility – best heard along left sternal border, but is also well heard at right 2 nd space and apex . Left sternal border murmur of AR causes Right sternal border murmur of AR causes Rheumatic heart disease Congenital bicuspid valve IE AR in association with valvular AS or subvalvular fixed AS Prosthetic AR Syphilis Marfan syndrome Ankylosing spondylitis Rheumatoid arthritis AR associated with TOF or VSD

34. AR murmur Character- high frequency / soft / blowing/ musical Thrill is rare Length of the murmur correlates with severity

35. AR murmur Causes of AR with short or no murmur a/c AR LVF Tachycardia Hypotension Vasodilators Pregnancy

36. Relation to physiological act Respiration and posture – best heard in sitting ( or standing ) leaning forward , held in expiration Isometric hand grip - ↑ Vasopressor - ↑ Vasodilator - ↓ Squatting - ↑

37. 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

38. Auscultatory events or murmurs simulating AR Auscultatory event /murmur Differentiating feature PR 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

39. Cole- Cecil murmur AR murmur in left axilla due to higher position of apex

40. 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

41. 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

42. 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

43. PR with normal pressure Feature 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 act Posture Respiration Incrs during supine / passive leg raising . Decrs with standing Incrs with inspiration.Decrs with exprn

44. 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

45. 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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