Systolic murmur

description of systolic murmurs

1. Dr Sujaya Raghavendra Systolic murmurs

2. Definition Prolonged vibration due to disturbance in blood flow that manifests as turbulence. Site of maximum intensity generally corresponds to the site of turbulence.

3. Areas of auscultation

4. Cardiac cycle

5. It is produced due to: Due to increased blood flow from a normal or abnormal orifice Through a narrowed orifice to a dilated chamber Backflow flow through an incompetent valve

6. Mechanism of murmur Due to turbulent blood flow It arises when the Reynolds number reaches > 2000 i.e 1.when blood flow velocity is high 2.orifice (vessel/chamber) diameter is small 3. Kinetic viscosity is low Reynold number = flow / [2 (diameter) x kinetic velocity]

7. Consequence of turbulence Vortex shedding: as the blood flow passes the narrow orifice , vortices produced at the tip of the orifice are shed laterally to hit the vessel wall producing vibrations and thereby a high pitched murmur Jet impact: a jet turbulent flow hit wall of heart or blood vessel Cavitations : a high turbulent flow producing theoretically micro – bubbles that generate a sound of different frequencies – harsh murmur

8. Eddies : a high velocity jet of blood produces currents in the adjacent slow moving blood . These eddies cause vibrations transmitted to the soft tissue and skin surface, resulting in murmur Periodic wake phenomena : as blood passes to either side of a structure a periodic wake phenomena arises , producing relatively pure musical tones . Flitter: A high speed jet of blood in a blood vessel may pull the wall of blood vessel inward by “Bernoulli effect” ,which causes vibrations in the vessel wall hence generating a murmur .

9. VORTEX SHEDDING PERIODIC WAKE PHENOMENA Vortices- oscillating flow that takes place when a fluid such as air / water flows opposing a streamlined flow at certain velocities Wake: disturbed flow or turbulence downstream of a solid body moving through a fluid medium .

10. Characteristics of murmur Timing in relation to heart sounds Location Duration or length Intensity Frequency or pitch Configuration or shape Transmission of murmur Dynamic auscultation

11. Timing Systolic murmurs : murmur begins with or after S1 and ends or before S2 Diastolic murmurs begin with or after S2 and ends before the subsequent S1 Continuous murmur: begins in systole and continues without interruption through S2 into all or a part of diastole Further can be classified as early ,mid, late and pan ( holo )

12. LOCATION Murmurs at the apex ONLY AT APEX BEST HEARD SOMEWHERE ELSE BUT ALSO HEARD AT APEX NOT HEARD AT APEX Systolic murmur of MR ESM of AS Murmurs of right sided origin (but can be heard when RV forms the apex ESM of calcified AS in elderly patients with emphysema (loss of jet effect) Pansystolic murmur of TR , VSD ESM of PS MDM of MS MDM of TS EDM of PR Functional MDM of MR

13. Murmurs at tricuspid area AT TRICUSPID AREA ONLY BEST HEARD SOMEWHERE ELSE BUT ALSO HEARD AT TRICUSPID AREA NOT HEARD AT TRICUSPID AREA Systolic murmur of TR PSM of MR and VSD MDM of MS MDM of TS ESM of AS and PS

14. Murmurs at left sternal border of 3rd intercostal space ONLY AT LSB BEST HEARD ELSEWHERE BUT ALSO ALONG LSB NEVER HEARD PSM of VSD ESM of valvular PS,and TR MDM of MS ESM of infundibular PS EDM of AR

15. Murmurs at Pulmonary area BEST HEARD BEST HEARD ELSEWHERE BUT ALSO ALONG PA NEVER HEARD ESM of PS AS MDM of MS and TS Flow murmur of pulmonary origin in ASD VSD Continuous murmur of PDA MR,AR Murmur of sub pulmonary VSD

16. Murmurs at Aortic area BEST HEARD RARELY HEARD: ESM of PS ESM of AS( valvular , subvalvular ), aortic sclerosis Never heard : MDM OF MS EDM of AR

17. Duration /length of murmur Short , long or holo Duration of pressure gradient between the two sites or chambers reflects the severity of the lesion.(true for stenotic lesions like MS,AS,PS) Regurgitant murmurs(PSM) are longer than stenotic lesions and the length is not related to severity of the lesion (MR ,VSD, TR) as the very prsence of these lesions produce the murmur In aortic regurgiation length of the murmur better correlates than MR in severity but is not reliable

18. Grading(Freeman & Levine 1933) Grade of murmur Basis Grade 1 Faint murmur heard on careful auscultation Grade 2 Easily audible not loud Grade 3 Easily audible loud murmur but no thrill Grade 4 Murmur with thrill Grade 5 Grade 6 Murmur audible stethoscope audible to chest Murmur audible half an inch from the chest. Associated with thrill. GRADE 3/6 or more intensity of systolic murmur is clinically significant with few exceptions but diastolic murmur of any degree of intensity is organic in nature .

19. Factors affecting intensity of murmur Quantity and velocity of blood flow across the sound producing area i.e degree of turbulence 1.high output states , murmurs are accentuated while in hypo dynamic states intensity decreases 2. high velocity of blood flow through a small VSD produces loud murmur, whereas a large flow at low velocity through an ASD produces no murmur

20. Accentuated in thin individuals Obesity, pericardial or pleural effusion emphysema will reduce the intensity.

21. Functional murmurs and thrills SITE THRILL Organic LESION CAUSE Apex Diastolic MS Severe MR Carotids Systolic Aortic stenosis Severe AR Pulmonary area Diastolic PR Severe PAH Pulmonary area Systolic PS Moderate to large ASD Neck veins Continuous Mimicking PDA /AV fistula Cervical venous hum

22. Character and frequency Directly related to velocity of blood flow High pressure gradient – high pitched (soft in AR blowing in MR, musical in papillary muscle rupture Low pressure gradient – low pitched (rough – MS) Mixed frequency – harsh in ASD,VSD, PS, transmission seen

23. Configuration or shape of murmur Related to the pattern of blood flow velocity Help in identification of the lesion 1. Crescendo (increasing) – ESM of AS 2. Decrescendo (decreasing)-EDM of AR 3. crescendo- decrescendo – (diamond shaped )- systolic murmur of AS and PS 4. Plateau- (even or unchanged)- PSM of MR

24. Transmission of murmurs Conduction occurs when there is direct anatomical continuity is present – systolic murmur of AS to carotids , PSM of MR to left axilla or back. loud murmurs transmit widely whereas soft murmurs are confined to their area of origin High frequency murmur or sound transmits proximally to its origin while low frequency goes distally. Low frequency murmur transmits better through the thorax and can be felt as thrill as compared to high frequency murmur.

25. Table

26. Systolic murmurs Classified into two basic categories : Ejection mid systolic murmur Regurgitant murmur Systolic ejection murmurs – forward flow across the LV or RF out flow tract. Systolic regurgitant murmurs – retrograde flow from a high pressure cardiac chamber to a low pressure cardiac chamber

27. Ejection systolic murmurs It begins shortly after the pressure in RV or LV exceeds the aortic or pulmonic diastolic pressure sufficiently to open the aortic or pulmonic valve There is a delay between the s1, which occurs after AV pressure cross over and the beginning of the murmur.

28. The murmur is a crescendo- decresendo type (diamond shaped or spindle shaped in configuration). Intensity of the murmur is proportional to the rate of ventricular ejection The shape depends on the instantaneous flow velocity during the ejections Flow characteristics of normal RV ejections are of rounded contour As early ejection rates are not high and flow curve peaks are late( ASD , straight back syndrome ) If LV or RV obstruction is severe systole is prolonged and the closure sound of the semilunar valve is delayed.

29. Innocent murmur Systolic ejection in nature Without the evidence of physiologic or structural abnormalities in CVS Grade < 3/6 No radiation to carotids or axilla Flow across the normal LVOT/RVOT 30-50% childeren

30. Still s murmur Young children 3-8 years , disappears by puberty flow across normal LVOT Related to small ascending aorta diameter with a concomitant high aortic blood flow velocity Short medium frequency murmur Croaking or buzzing in character Best heard : left sternal border at the 3 rd or 4 th ICS.

31. Innocent Pulmonary murmur Common in children , adolescents, and young adults . Flow across RVOT low to medium frequency mid systolic Blowing character Best heard: PA with radiation to left sternal border

32. LVOT obstruction Causes valvular supravalvular subvalvular rheumatic Hour glass type HOCM Bicuspid/ unicuspid valve Diffuse type Discrete membranous Acommissural / unicomissural with eccentric opening Aortic dissection Tunnel type Myxoid dysplasia Healing aortotomy site hyperlipidemia Rubella Fabry s disease Calcific degenerative

33. Features of aortic stenosis murmur Site of best audibilty Aortic area (second right ICS ) rt sternal border , apex conducted to the neck vessels ( rt carotid) Timing Ejection systolic Grade Usually 3/6 Length of murmur Short , medium or long Relation to physiological act Does not increase on inspiration Decrease on standing and valsalva character harsh Accompanying features Slow rising arterial pulse Sustained left ventricular impulse S4, ejection click Symptoms of angina , syncope and dyspnoea

34. Site of best audibilty /selective conduction significance Best audible at Right second space conducted to carotid Valvular non calcific AS, congenital bicuspid AS ( withsystolic ejection sound) Best audible at left sternal border , no conduction Subvalvular AS(fixed or dynamic) Calcific AS Mistaken VSD/MR Carotid murmur with/without right second space murmur Supravalvular AS( elfien facies ) Carotid stenosis Audible only at apex Calcific AS in elderly with emphysema Mistaken as MR(not radiated to axilla )

35. Length of the murmur Longer the murmur and later in systole peaks , more the severity of AS Duration is the reflection of the pressure difference across the valve Any change in the cardiac output makes the severity of the lesion unreliable Overestimation can be made in high output states like anemia, thyrotoxicosis , pregnancy associated AR ,PDA anxiety

36. Condition Mechanism CCF Low cardiac output Polycythemia Increased viscosity of blood Associated with proximal obstruction MS,TS, low CO Associated with proximal regurgitation or shunt MR,VSD Associated with SHT/ coarctation Obliteration of gradient CAD/MI/ Hypothyroidism Elderly female AF Low cardiac output UNDER ESTIMATION OF THE MURMUR

37. Gallavardin phenomena Elderly patient with aortic sclerosis/AS due to fibro calcific changes have gallavardin dissociation Two distinct mid diastolic murmurs are heard – A noisy medium pitched murmur at the right second space(due to turbulence caused by the high velocity jet within aortic root) A high frequency musical murmur at the apex (due to periodic wake phenomena caused by high frequency vibrations of the fibrocalcific aortic cusps Simulates murmur of MR but without radiation to the axilla or back or is accentuated with slowing of heart rate such as a compensatory pause or pre mature beat

38. Relationship with physiological act maneuver Fixed obstruction (AS) Dynamic obstruction (HOCM) Respiration No change Increase with expiration Standing decrease increase valsalva decrease increase Squatting increases decreases HOCM is associated with pulsus bisfirens with double or triple apex A2 is of normal intensity and S2 maybe single or reversed split Usually doesnot exceed grade 3 intensity Murmur decreases with increase in preload or afterload (squatting, passive leg raising vasopressors ) or reduce contractility(B blockers ) and increases with inotropic administration Best heard : apex & lower left sternal edge.

39. FEATURE Aortic valve sclerosis AS murmur Short medium pitched Long/rough AR Absent Maybe present A2 Normal /increased Diminished or absent S2 Normal split Single / reversed split LVH absent present S4 Absent Maybe present Calcification rare Maybe present Arterial pulse Normal Slow rising

40. Other features The slow rising and sustained pulse ( pulsus parvus et tardus ) Is accompanied with a long ejection systolic murmur and a delayed peak Normal arterial pulse is consistent with a short ejection murmur with early peak

41. Arterial pulse is normal + long ejection murmur- likely to be MR(along with S3)/VSD long ejection murmur+ S4- fixed obstruction (AS) Short murmur or no murmur(decreased ventricular compliance) + S4- Dynamic obstruction –HOCM . Ejection click(mobile non calcific valve - PS>AS

42. AR with AS Fixed valvular or subvalvular obstruction is likely The accompanying systolic murmur is likely due to AS or VSD and not due to PS A “new murmur” of AR in AS may mean infective endocarditis in a febrile patient with AS.

43. Summary

44. Valvular PS Congenital or acquired usually with intact ventricular septum Best heard: left 2 nd - 3 rd ICS , (conducted to the left supraclavicular and left side of the neck Begins with systolic ejection sound (accentuates with expiration) , severe PS the ejection sound fuses with S1 and S4. Early peaking with a short duration or a late peaking with prolonged duration- severity of obstruction

45. P2 soft S2 split widens – increasing severity of stenosis Prominent a waves in JVP, left parasternal heave, And RV S4 which increases with inspiration Associated with PR in dysplastic pulmonary valve(Noonan s syndrome) or with IE Hypertelorism and moon facies

46. It increases with inspiration Decreases on standing , valsalva Grade 4/6

47. Infundibular PS Associated with TOF Best heard – 3 rd left ICS Shorter as severity of obstruction increases Ejection click can be there Shortens and decreases in intensity with amyl nitrate inhalation P2 absent

48. Supravalvular PS Maybe associated with supravalvular AS Best heard: upper left sternal border, infraclavicular region and laterally Murmur is Less harsh high pitched with varying intensity. On branched PA stenosis : murmur is heard more laterally with transmission to right chest , back and both axillae . Can become continuous with increased severity

49. Functional murmurs Due to dilatation of aortic root Dilatation of pulmonary artery Due to increased flow into aorta Due to increased flow into the PA Sclerotic aorta in elderly Idiopathic PA dilatation Pregnancy ASD Dilated PA secondary to PAH Anemia VSD Thyrotoxicosis straight back syndrome and pectus excavatum Fever Peripheral A-V Fistula

50. Regurgitant murmurs

51. Early systolic murmur High pitch Decrescendo Begin at S1 and end well before S2 , mid systole Regurgitant murmurs flow from high pressure chamber to low pressure cardiac chamber. Acute severe MR(associated with exp. Split S2) TR(with normal RV systolic pressure) Small VSD or non restrictive VSD with PAH

52. Regurgitant or holosystolic or Pansystolic murmur High pitched Blowing in quality Produced by retrograde flow from high chamber to low chamber . Begins with S1 occupies whole of systole and ends with S2 at its origin Causes Chronic MR Chronic TR Restrictive VSD Aorto - pulmonary connection : AP window and PDA with PAH(rise in PVR abolishes the diastolic portion of continuous murmur and PSM is audible)

53. CHRONIC MR LV Pressure exceeds the LA throughout systole High pitched , blowing in quality, plateau like in configuration grade 3/6 in intensity No thrill No little variation with respiration /cardiac cycle during arrhythmias Best heard: apex , radiating to left axilla , angle of the scapula and occasionally to the vertebral column .

54. Anterior mitral leaflet involvement : the regurgitant jet is directed posterolaterally within LA with bone conduction from cervical to lumbar spine . Posterior mitral leaflet: left sternal edge, base and may even radiate into the neck when the direction of the intra – atrial jet is forward and medial against the interatrial septum. Presence of LVS3 with muffled S1- significant MR.

55. Chronic TR Holosystolic – RV pressure is elevated or secondary to PAH/PS Soft , high pitched and blowing Grade <3/6 Increases in intensity with inspiration ( Carvallo ’ s sign ) but absent when associated with severe RV failure or organic TR

56. In severe RV failure , RV fails to take up additional venous return with inspiration , CO falls , decrease in murmur Associated organic TS with TR prevents increase in venous return into RV, hence murmur decreases

57. Best heard at the lower left sternal border (Tricuspid area) with no selective radiation RV forms apex , murmur can be heard t the apex (simulating MR) Associated with prominent ‘v’ wave with rapid ‘y’ decent in JVP RVS3,left parasternal heave . Organic TR:murmur is non- holosystolic low frequency , RV systolic pressure normal.

58. Murmur of VSD(restrictive ) Left ventricular systolic pressure and systemic vascular resistance exceed right ventricular systolic pressure and pulmonary vasculature resistance from the onset to the end of systole. Medium pitched harsh , >4/6 grade and associated with thrill Best heard along the left sternal border in 3 rd to 5 th ICS spaces during expiration

59. Supracristal VSD: PA conducted to infraclavicular area and left neck (confused with PS In Gerbode’s defect (VSD of LV to RA) – murmur conducted to right sternum VSD of L- TGA may be best heard at the apex Valsalva maneuver and amyl nitrate inhalation decrease the murmur intensity

60. Non PSM – large non restrictive VSD(>0.8cm sq. /meter sq.), Very small VSDs, multiple VSDs Eisenmanger syndrome (pulmonary ESM maybe present )

61. SUMMARY Features MR TR VSD Best heard apex Lower left sternal area Left sternal border in 3 rd -4 th ICS Selective transmission Radiation to axilla and back No No Thrill Rare (with chordal rupture ) - common Character High pitched , blowing High pitched , soft and blowing Medium pitched , rough and harsh Respiration No change Increases during inspiration Increases during expiration Accompanying features Eccentric left ventricular hypertrophy , soft S1, LV S3 Right ventricular hypertrophy ‘v ‘ wave in JVP .signs of PAH Biventricular enlargement and have signs of PH

62. Late systolic murmur Begin at mid to late systole and proceed upto S2 MVP – prolapse of posterior mitral leaflet High pitched Musical quality(whoop or honk) Best heard : apex introduced by single or multiple ejection clicks

63. Thank you