Murmur
Definition: Murin~lr is a series of audito~y vibrations that are more prolonged than a so~ulld.
iii) Supravalvular Aortic Stenosis Murmur
Characteristic: Murmur may be loudest in 1st Right ICS. It isn't associated with systolic ejection click.
iv) Discrete Subvalvirlar Stertosis Murmirr
Characteristic: Systolic ejection click is absent and almost invariably murmur of AR is present.
Pulmonary Stenosis Ejection Murmur
- Valvalar PS
- Supravalvular PS (Narrowing of pulmonary trunk or its branches)
- Subvalvular PS (Infi~ndibular PS).
Valvular PS Murmur
Characteristic: Harsh crescendo-decrescendo murmur along the left sternal border and loudest at pulmonary area, conducted to left shoulder and associated with systolic ejection click. As stenosis becomes more severe, the crescendo-decrescendo systolic m m u r peaks later in systole and the ejection click moves closer to S1.Patients with TOP physiology (VSD and PS), the murmur of PS becomes softer and shorter as the severity of PS increases. This is because more blood flows from RV to LV via the VSD than from RV to PA. This is in contrast to patients with PS with intact septum, in whom the murmur get louder and longer with increasing severity.Amy1 Nitrite inhalation softens the murmur in patients with VSD and PS but increases the murmur in patients with PS and intact septum..Evaluatiotl of Patient:
Systolic Regurgitant Murmur Characteristh:
These start with S1 and extend to or beyond S2. They are predominantly high pitched and tend to remain the same after sudden long diastole(as against systolic ejection murmurs which get louder).MI$ Mur,mur Chronic MR Murmur Characteristic: Pan systolic mwmur, often loudest at apex and radiates to axilla, may also be audible in back and over the entire precordium.The longer and louder the mu11nur, more severe is MR. Acute MR Murmur MR due to ruptured papillary muscle, ruptured chordae tendinae, or due to Infective ~ndocarditis/~yocardial infarction.
Chal'actel-istic: A systolic murmur is heard at apex, at times parsystolic and other times it diminished or increases in amplitude in late systole. It may radiate to the base and hence confuse with murmur of AS when it is due to rupture of posterior papillary muscle or its chordae tendinae. If anterior papillary muscle niptures, it radiates to the back. The intensity of murmur doesn't bear any relation to the severity of MR.Acute MR murmurs may have S, associated, which is rare in chronic rheumatic MR.
Definition: Murin~lr is a series of audito~y vibrations that are more prolonged than a so~ulld.
Causes: High-energy turbulence call occur due to:
1)High velocity flow.
2) Local obstruction or fluid flowing into a channel of larger dimension.
3)Combined effect causing vertices and vibratoly waveforms.
Grading of Murmurs: As recommended by Levine in 1933.
Grade 1 : Very faint munnur that can be heard only with special effort.
Grade 2: Soft but readily detected murmur.
Grade 3: Prominent but not loud murmur.
Grade 4: Loud murmur.
Grade 5: Very loud ilnmnur can often be heard with rim of stethoscope touching the skin.
Grade 6: Murmur loud enough to be heard with stethoscope just removed From contact with chest wall.Grade 4, 5 and 6 murmurs are always accompanied by a thrill.These begin with S,, are crescendo decrescendo in nature and finish before A, (if left sided ejection murmur) or P, (if right sided ejection murmur) and are low to medium frequency sounds even when soft.
The two conlmon types of ejection murmurs are:
a) Aortic or pulmonary stenosis ejection murmur.
b) Systolic flow murmur.
1)High velocity flow.
2) Local obstruction or fluid flowing into a channel of larger dimension.
3)Combined effect causing vertices and vibratoly waveforms.
Grading of Murmurs: As recommended by Levine in 1933.
Grade 1 : Very faint munnur that can be heard only with special effort.
Grade 2: Soft but readily detected murmur.
Grade 3: Prominent but not loud murmur.
Grade 4: Loud murmur.
Grade 5: Very loud ilnmnur can often be heard with rim of stethoscope touching the skin.
Grade 6: Murmur loud enough to be heard with stethoscope just removed From contact with chest wall.Grade 4, 5 and 6 murmurs are always accompanied by a thrill.These begin with S,, are crescendo decrescendo in nature and finish before A, (if left sided ejection murmur) or P, (if right sided ejection murmur) and are low to medium frequency sounds even when soft.
The two conlmon types of ejection murmurs are:
a) Aortic or pulmonary stenosis ejection murmur.
b) Systolic flow murmur.
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| Aortic stenosis-murmur |
i)Valvar Aortic Stenosis Murmurs
Characteristic: Harsh, rasping crescendo-decrescendo murnlur best heard anywhere in a straight line from right 2nd ICS to apex ("sash" area), with radiation to neck.Gallaverdin 'Phenomenon: In elderly adults with previously normal tricuspid aortic valves rendered sclerotic or stenotic by fibrocalcific changes, two components of the murmur can be heard - a harsh and noisy one over right 2nd ICS which originates within the aortic root due to turbulence caused by high velocity jet and a musical one heard over the left ventricular impulse originating from. the periodic high frequency vibration of fibrocalcific aortic cusps and mimicking the inurmur of MR.The shorter the inurmur and later the peak, more severe is the AS in contrast PS where murmur gets longer as stenosis gets more severe. Other auscultatory findings of severe. AS are soft or absent A,, reversed splitting of S, and presence of S,.
Characteristic: Harsh, rasping crescendo-decrescendo murnlur best heard anywhere in a straight line from right 2nd ICS to apex ("sash" area), with radiation to neck.Gallaverdin 'Phenomenon: In elderly adults with previously normal tricuspid aortic valves rendered sclerotic or stenotic by fibrocalcific changes, two components of the murmur can be heard - a harsh and noisy one over right 2nd ICS which originates within the aortic root due to turbulence caused by high velocity jet and a musical one heard over the left ventricular impulse originating from. the periodic high frequency vibration of fibrocalcific aortic cusps and mimicking the inurmur of MR.The shorter the inurmur and later the peak, more severe is the AS in contrast PS where murmur gets longer as stenosis gets more severe. Other auscultatory findings of severe. AS are soft or absent A,, reversed splitting of S, and presence of S,.
HOCM:Murmur
Charstevistic: The murmur is harsh, crescendo-decrescendo audible along the left sternal border, radiates to the base of heart but not well-appreciated over-the carotids.Systolic ejection clicks are absent.The obstruction in HOCM is due to the hypertrophied septum-which bulges into the LVOT during systole together with systolic anterior motion of the anterior mitral leaflet (Bernoulli effect). Both these contribute to make the LVOT narrow.The'murmur inc~eases in intensity with any manoeuvre that reduces left ventricular cavity size or increases contractility like valsalva manoeuvre,administration of amyl nitrite, beat following a VPB.
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| Clinical findings in HOCM |
Characteristic: Murmur may be loudest in 1st Right ICS. It isn't associated with systolic ejection click.
iv) Discrete Subvalvirlar Stertosis Murmirr
Characteristic: Systolic ejection click is absent and almost invariably murmur of AR is present.
Pulmonary Stenosis Ejection Murmur
- Valvalar PS
- Supravalvular PS (Narrowing of pulmonary trunk or its branches)
- Subvalvular PS (Infi~ndibular PS).
Valvular PS Murmur
Characteristic: Harsh crescendo-decrescendo murmur along the left sternal border and loudest at pulmonary area, conducted to left shoulder and associated with systolic ejection click. As stenosis becomes more severe, the crescendo-decrescendo systolic m m u r peaks later in systole and the ejection click moves closer to S1.Patients with TOP physiology (VSD and PS), the murmur of PS becomes softer and shorter as the severity of PS increases. This is because more blood flows from RV to LV via the VSD than from RV to PA. This is in contrast to patients with PS with intact septum, in whom the murmur get louder and longer with increasing severity.Amy1 Nitrite inhalation softens the murmur in patients with VSD and PS but increases the murmur in patients with PS and intact septum..Evaluatiotl of Patient:
Systolic Regurgitant Murmur Characteristh:
These start with S1 and extend to or beyond S2. They are predominantly high pitched and tend to remain the same after sudden long diastole(as against systolic ejection murmurs which get louder).MI$ Mur,mur Chronic MR Murmur Characteristic: Pan systolic mwmur, often loudest at apex and radiates to axilla, may also be audible in back and over the entire precordium.The longer and louder the mu11nur, more severe is MR. Acute MR Murmur MR due to ruptured papillary muscle, ruptured chordae tendinae, or due to Infective ~ndocarditis/~yocardial infarction.
Chal'actel-istic: A systolic murmur is heard at apex, at times parsystolic and other times it diminished or increases in amplitude in late systole. It may radiate to the base and hence confuse with murmur of AS when it is due to rupture of posterior papillary muscle or its chordae tendinae. If anterior papillary muscle niptures, it radiates to the back. The intensity of murmur doesn't bear any relation to the severity of MR.Acute MR murmurs may have S, associated, which is rare in chronic rheumatic MR.
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| Murmurs |
MVP Murmur
Characteristic: Mid systolic click followed by a late systolic nmmur which ~zsually extends to A2. i'he click may be absent and is not always followed by the late systolic murmur. Occasionally, murmur is high pitched and has been described as musical honk or whoop. In most patients with MVP, MR is trivial. Any maneuver that decreases the LV volume such as prompt standing, straining phase of Valsalva maneuver, amyl nitrite i.nhalation causes the valvular prolapse to occur earlier in systolic and therefore, the click and rnurnl'ur move closer to S 1.
TR Murmur Chnracteristic:
Holosystolic murmur, loudest at left lower-sternal border and becomes louder with inspiration (Carvallo sign).
VSD Murmur
Clzaracteristic: The murmur of a moderate or large VSD is holosystolic and loudest along the lower left sternal border and is usually accompanieh by a thrill.With development of pulmonaiy NT, the pressure gradient between left and right ventricle diminishes; Hence, the systolic murmur and thrill soften and finally disappear.Small, muscular VSD may produce prominent high-frequency ejection systolic murmur that end before the end of systole if the contracting septa1 ~nuscle closes the defect.
In the setting of acute MI, a pansystolic inurmur due to VSD can be differentiated from that due to nlptured papillary muscle:
- More than 50 per cent of VSD murmurs are associated with thrill and are loudest medial to apex.
- MR ~lulmurs are very rarely associated with tlxill and are loudest lateral to apex.
Characteristic: Mid systolic click followed by a late systolic nmmur which ~zsually extends to A2. i'he click may be absent and is not always followed by the late systolic murmur. Occasionally, murmur is high pitched and has been described as musical honk or whoop. In most patients with MVP, MR is trivial. Any maneuver that decreases the LV volume such as prompt standing, straining phase of Valsalva maneuver, amyl nitrite i.nhalation causes the valvular prolapse to occur earlier in systolic and therefore, the click and rnurnl'ur move closer to S 1.
TR Murmur Chnracteristic:
Holosystolic murmur, loudest at left lower-sternal border and becomes louder with inspiration (Carvallo sign).
VSD Murmur
Clzaracteristic: The murmur of a moderate or large VSD is holosystolic and loudest along the lower left sternal border and is usually accompanieh by a thrill.With development of pulmonaiy NT, the pressure gradient between left and right ventricle diminishes; Hence, the systolic murmur and thrill soften and finally disappear.Small, muscular VSD may produce prominent high-frequency ejection systolic murmur that end before the end of systole if the contracting septa1 ~nuscle closes the defect.
In the setting of acute MI, a pansystolic inurmur due to VSD can be differentiated from that due to nlptured papillary muscle:
- More than 50 per cent of VSD murmurs are associated with thrill and are loudest medial to apex.
- MR ~lulmurs are very rarely associated with tlxill and are loudest lateral to apex.
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