0 valutazioniIl 0% ha trovato utile questo documento (0 voti)
38 visualizzazioni6 pagine
The presence of this murmur is a good positive predictor for aortic regurgitation. Mid-diastolic mitral stenosis is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. A Coronary artery bypass surgery can eliminate the murmur.
The presence of this murmur is a good positive predictor for aortic regurgitation. Mid-diastolic mitral stenosis is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. A Coronary artery bypass surgery can eliminate the murmur.
The presence of this murmur is a good positive predictor for aortic regurgitation. Mid-diastolic mitral stenosis is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. A Coronary artery bypass surgery can eliminate the murmur.
Early diastolic Aortic regurgitation The murmur is low intensity, high-pitched, best heard over the left sternal border or over the right second intercostal space, especially if the patient leans forward and holds breath in full expiration. The radiation is typically toward the apex. The configuration is usually decrescendo and has a blowing character. The presence of this murmur is a good positive predictor for AR and the absence of this murmur strongly suggests the absence of AR. An Austin Flint murmur is usually associated with significant aortic regurgitation. Early diastolic Pulmonary regurgitation Pulmonary regurgitation is most commonly due to pulmonary hypertension (Graham-Steell murmur). It is a high-pitched and blowing murmur with a decrescendo configuration. It may increase in intensity during inspiration and best heard over left second and third intercostal spaces. The murmur usually does not extend to S1. Early diastolic Left anterior descending arterystenosis This murmur, also known as Dock's murmur, is similar to that of aortic regurgitation and is heard at the left second or third intercostal space. A Coronary artery bypass surgery can eliminate the murmur.
Mid-diastolic[edit] Time Condition Description Mid- diastolic Mitral stenosis This murmur has a rumbling character and is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. It usually starts with an opening snap. In general, the shorter the duration (S2 to Opening Snap), the more severe the mitral stenosis. However, this rule can be misleading in situations where the stenosis is so severe that the flow becomes reduced, or during high-output situations such as pregnancy where a less severe stenosis may still produce a strong murmur. In mitral stenosis, tapping apical impulse is present. Mid- diastolic Tricuspid stenosis Best heard over the left sternal border with rumbling character and tricuspid opening snap with wide splitting S1. May increase in intensity with inspiration (Carvallo's sign). Tricuspid stenosis often occurs in association with mitral stenosis. Isolated TS are often associated with carcinoid disease and right atrial myxoma. Mid- diastolic Atrial myxoma Atrial myxomas are benign tumors of the heart. Left myxomas are far more common than right myxomas and those may cause obstruction of the mitral valve producing a mid-diastolic murmur similar to that of mitral stenosis. An echocardiographic evaluation is necessary. Mid- diastolic Increased flow across the atrioventricular valve This can also produce a mid-diastolic murmur, such as in severe mitral regurgitation where a large regurgitant volume in the left atrium can lead to "functional mitral stenosis." Mid- diastolic Austin Flint murmur An apical diastolic rumbling murmur in patients with pure aortic regurgitation. This can be mistaken with the murmur in mitral stenosis and should be noted by the fact that an Austin Flint murmur does not have an opening snap that is found in mitral stenosis. Mid- diastolic Carey-Coombs murmur A mid-diastolic murmur over the left ventricular impulse due to mitral valvulitis from acute rheumatic fever.
Mid-systolic ejection[edit] Time Condition Description Mid- systolic ejection Aortic outflow obstruction (Aortic Stenosis) Can be due to aortic valve stenosis or hypertrophic cardiomyopathy (HCM), with a harsh and rough quality. **Valvular aortic stenosis can produce a harsh, or even a musical murmur over the right second intercostal space which radiates into the neck over the two carotid arteries. The most common cause of AS (Aortic Stenosis) is calcified valves due to aging. The second most common cause is congenital bicuspid aortic valves (normal valve is tricuspid). In aortic stenosis, heaving apical impulse is present. The distinguishing feature between these two causes is that bicuspid AS has little or no radiation. It can be confirmed if it also has an aortic ejection sound, a short early diastolic murmur, and normal carotid pulse. The murmur in valvular AS decreases with standing and straining with Valsalva maneuver. ** Supravalvular aortic stenosis is loudest at a point slightly higher than in that of valvular AS and may radiate more to the right carotid artery. **Subvalvular aortic stenosis is usually due to hypertrophic cardiomyopathy (HCM), with murmur loudest over the left sternal border or the apex. The murmur in HCM increases in intensity with a standing position as well as straining with Valsalva maneuver. Mid- systolic Pulmonic outflow obstruction(Pulmonic A harsh murmur usually on left second intercostal space radiating to left neck and accompanied by palpable thrill. ejection Stenosis) It can be distinguished from a VSD (Ventricular septal defect) by listening to the S2, which is normal in VSD but it is widely split in pulmonary stenosis. However, VSD is almost always pansystolic where the murmur of pulmonary stenosis is diamond-shaped and ends clearly before S2. Many innocent murmurs also arise from this location but S1 and S2 must split normally. Mid- systolic ejection Dilation of aortic root or pulmonary artery Produces an ejection sound, with a short ejection systolic murmur and a relatively wide split S2. There is no hemodynamic abnormality. This is similar to pulmonary hypertension except the latter has hemodynamic instabilities. Mid- systolic ejection Increased semilunar blood flow This can occur in situations such as anemia, pregnancy, or hyperthyroidism. Mid- systolic ejection Aortic valve sclerosis This is due to degenerative thickening of the roots of the aortic cusps but produces no obstruction and no hemodynamic instability and thus should be differentiated from aortic stenosis. It is heard over right second intercostal space with a normal carotid pulse and normal S2. Mid- systolic ejection Innocent midsystolic murmurs These murmurs are not accompanied by other abnormal findings. One example of a benign paediatric heart murmur is Still's murmur in children. Late systolic[edit] Time is important Condition Description Late systolic Mitral valve prolapse This is the most common cause of late systolic murmurs. It can be heard best over the apex of the heart, usually preceded by clicks. The most common cause of mitral valve prolapse is "floppy" valve (Barlow's) syndrome. If the prolapse becomes severe enough, mitral regurgitation may occur. Any maneuver that decreases left ventricular volume such as standing, sitting, Valsalva maneuver, and amyl nitrate inhalation can produce earlier onset of clicks, longer murmur duration, and decreased murmur intensity. Any maneuver that increases left ventricular volume such as squatting, elevation of legs, hand grip, and phenylephrine can delay the onset of clicks, shorten murmur duration, and increase murmur intensity. Late systolic Tricuspid valve prolapse Uncommon without concomitant mitral valve prolapse. Best heard over left lower sternal border. Late systolic Papillary muscle dysfunction Usually due to acute myocardial infarction or ischemia, which causes mild mitral regurgitation. Holosystolic (pansystolic)[edit] Time Condition Description Holosystolic (pansystolic) Tricuspid insufficiency Intensifies upon inspiration. Can be best heard over the fourth left sternal border. The intensity can be accentuated following inspiration (Carvallo's sign) due to increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein's anomaly, carcinoid disease, or prior right ventricular infarction. Holosystolic (pansystolic) Mitral regurgitationor MR No intensification upon inspiration. In the presence of incompetent mitral valve, the pressure in the L ventricle becomes greater than that in the L atrium at the onset of isovolumic contraction, which corresponds to the closing of the mitral valve (S1). This explains why the murmur in MR starts at the same time as S1. This difference in pressure extends throughout systole and can even continue after the aortic valve has closed, explaining how it can sometimes drown the sound of S2. The murmur in MR is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary MR. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe MR. Holosystolic (pansystolic) Ventricular septal defect No intensification upon inspiration. VSD is a defect in the ventricular wall, producing a shunt between the left and right ventricles. Since the L ventricle has a higher pressure than the R ventricle, flow during systole occurs from the L to R ventricle, producing the holosystolic murmur. It can be best heard over the left third and fourth intercostal spaces and along the sternal border. It is associated with normal pulmonary artery pressure and thus S2 is normal. This fact can be used to distinguish from pulmonary stenosis, which has a wide splitting S2. When the shunt becomes reversed ("Eisenmenger syndrome"), the murmur may be absent and S2 can become markedly accentuated and single.