Murmurs and Myocardial SoundsMaking Sense of the Madness

Murmurs and Myocardial SoundsMaking Sense of the MadnessSara G. Tariq, M.D.August, 20121GoalsKnow how we classify murmursSystolicCrescendo-decrescendoAortic stenosis, pulmonic stenosis, or innocent murmurHolosystolicMitral regurg, tricuspid regurg or VSDLate Systolic - MVPDiastolicAortic regurgitation, pulmonic regurgitationStenosis of mitral or tricuspidBothPatent Ductus Arteriosus2GoalsKnow the significance of rubsKnow the significance of extra soundsSplit S2 (varies vs split)S3S43What are murmurs?SoundsMurmurs exist because of turbulent blood flow or increased velocity of blood flow across an orifice (a valve)Usually 3 different kinds of soundsHolosystolic, crescendo-decrescendo or decrescendo,

4Does sound matter?Most murmurs will worsen with smaller orifice sizeso a very large VSD may have almost no pressure gradient across its mouth and thus little murmur but very large physiologic consequences. Conversely, a small VSD may have a very turbulent jet with high velocity and a high pressure gradient across its mouth and be associated with a loud murmur, but have a much lower hemodynamic significance.

5Grading the SoundI-faintest murmur that can be heard (with difficulty)II- murmur is also a faint murmur but can be identified immediatelyIII- moderately loudIV- loud with a palpable thrillV- very loud, but still need stethoscopeVI- loudest and can be heard without stethoscope

7S1 and S2Closing of the mitral (tricuspid, too) and aortic (pulmonic, too) valvesUsually very crispYou should hear S1 loudest at mitral areaYou should hear S2 loudest at aortic area

8Where do you hear murmurs?RUSB= (may radiate to neck)LUSB=Pulmonic (may radiate to back)LLSB=Tricuspid (usually doesnt radiate)Apex=Mitral (may radiate to axilla)

9Systolic murmurs swooshing soundsOccur right after S1 (closing of mitral valve) and before S2 (closing aortic v)Causes:having trouble getting out of the ventricle through a tight door (aortic stenosis)You fall out through a door which should be closed tight but isnt (mitral reg)A hole exists where it shouldnt in the ventricular septum and blood crosses from high pressure side to low pressure side (VSD)

10Mitral regurgitation

11Mitral regurgitationMitral valve is incompetent and does not close properly (door wont close) Result: abnormal leaking of blood from the LV, through the mitral valve, and into the left atrium Causes: myxomatous degeneration, MI, dilated LVSound: holosystolic (swoosh lasts throughout systole) radiates to axilla12Mitral and tricuspid valves like a parachute

13Systolic MurmursMitral Regurgitation (apex)Systolic murmur Radiates to axilla

S1S1

S2

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Mitral valve prolapsedisplacement of an abnormally thickened mitral valve leaflet that gets displaced into the atrium in systoleMid-systolic click with late systolic murmurYou can get mitral regurg if severe15Aortic Stenosis

16Aortic stenosisThe aortic valve narrowsCreates turbulent blood flow across the narrowed valveResult- the heart has to work hard by creating pressure to get blood across the stenotic valveCauses: congenitally bicuspid valve, wear and tear from age, Rheumatic fever Sound: crescendo-decrescendo murmur in systole, radiates to carotids

17Physical Exam: CardiacRUSB with diaphragm; radiates to carotids bilaterally S1S1

S2

18VSD

19VSDCongenital hole in septumLeft heart pressures>right heart So in systole, when heart contracts, the blood in the left goes across the window into the right sideHolosystolic murmur, just like mitral regurgitationOnly difference is that it is usually over the sternal border

20SystolicVentricular Septal Defect ContinuousArteriovenous connections (PDA)

21Innocent murmurAKA physiologic murmurDoesnt radiateOccurs NOT from a structural problem in the heart but from something outside the heartHyperthyroidism, anemia

22Systolic MurmursInnocent murmursUsually diamond shaped, brief, little radiationCommon in children and young adultsALWAYS: systolic, < III/VI intensity, other heart sounds and pulses are normal

S1S1

S2

23Diastolic murmurs= really badSame swoosh but at a different timeYou hear it right after S2 and before S1Blood is having trouble leaving the atrium to the ventricle b/c door is partly shut (mitral stenosis) Ventricular outflow tract can not stay shut (aortic regurg)24Aortic Regurgitation

25Aortic regurgAortic valve can not close fullySome blood that should go forward to the body now comes back into the heartCauses:congenitally bicuspid valveYou hear the turbulence in diastole after aortic valve should have fully closed (after S2)

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27Diastolic MurmursAortic Regurgitation (Upper sternal)radiates inferiorly best heard with patient sitting up and leaning forward (in expiration)

S1S1

S2

28Mitral stenosis

29Mitral stenosisMitral valve is tight so blood can not get out of the atriumWhen the mitral valve area goes below 2cm, the valve causes an impediment to the flow of blood into the left ventricle, creating a pressure gradient across the mitral valve. Pressure=turbulence=murmurCauses: Rheumatic heart dz, damage from endocarditisSound: A mid-diastolic rumbling murmur will be heard after an opening snap. The murmur is best heard at the apical region and doesnt radiate

30Patent Ductus Arteriosis (PDA)In some babies the ductus arteriosus remains patent (connects pulm a and aorta)This opening allows oxygen-rich blood from the aorta to mix with oxygen-poor blood from the pulmonary artery. This can put strain on the heart and increase blood pressure in the lung arteries. 31PDASounds like continuous machinery murmur throughout systole and diastole

32SystolicVentricular Septal Defect ContinuousArteriovenous connections (PDA)

33Split S2Physiologically split S2Natural delay in closure of pulmonic valveWhy? increase in pulmonary blood flow that occurs with inspiration when increased venous return to the right side of the heart delays the closure of the pulmonic valve Fixed Split S2= ASDIncrease pulmonary blood flow from increased preload from L->R shunt of blood across ASD delays closure of pulmonic valveThis split doesnt change with respiration b/c ASD is more hemodynamically significant than the small increase in volume of blood that results from inspiration34Split S2Paradoxically Split S2You have split S2 in EXPIRATIONThis can only happen when the aortic valve is delayed in closing.A LBBB will cause delayed depolarization of the left ventricle and a slightly delayed closing of the aortic valve!!35S3Only be heard with the bell, never with the diaphragm .This helps distinguish it clinically from a widely split S2. Is heard after S2 It can be normal in children and young people if no other abnormalities are reported on exam.If other abnormalities are reported or the person is over 40, interpret this sound as caused by the blood entering a ventricle that is already volume and pressure overloaded (like CHF) 36S4Caused by blood entering a thickened, stiffened ventricle.Comes just before S1 in the cardiac cycleCan be left or right sidedCan occasionally be heard in athletes but more commonly found in ventricular hypertrophy states or infiltrative cardiomyopathies (amyloid etc) 37RubsPericardial rub= pericarditisThis is a velcro sound that you can hear throughout the cardiac cyclePericarditisRecent upper resp tract infectionChest pain that is better with leaning forward and worse with lying down

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