dr. r. tandon sitaram bhartia institute, new delhi
Post on 14-Dec-2015
217 Views
Preview:
TRANSCRIPT
Dr. R. TandonSitaram Bhartia Institute, New Delhi
Continuous MurmursContinuous Murmurs
Defn.Defn. :- :- A murmur starting in systole and A murmur starting in systole and
going through the S2 in diastole.going through the S2 in diastole.
A murmur present throughout the A murmur present throughout the cardiac cycle : covers S1, S2 whole cardiac cycle : covers S1, S2 whole of systole and diastole, may be of systole and diastole, may be louder in systole or diastole.louder in systole or diastole.
Continuous MurmursContinuous Murmurs
To & fro murmurTo & fro murmur :- :-
A gap between the systolic and A gap between the systolic and diastolic murmurs identifies diastolic murmurs identifies two separate murmurs.two separate murmurs.
Continuous MurmursContinuous Murmurs
Clinical SettingClinical Setting :- :- Cyanotic or acyanotic.Cyanotic or acyanotic. Features of aortic run offFeatures of aortic run off
- present, absent.- present, absent. Features of hyperkinetic circ.Features of hyperkinetic circ.
- present, absent.- present, absent. Cardiac chambers involvedCardiac chambers involved
- all or partial.- all or partial.
Continuous MurmursContinuous Murmurs
Acyanotic patientsAcyanotic patients :- :-
PDA PDA S. of Valsalva-RA/RV S. of Valsalva-RA/RV
fistulafistulaCoron. AV fistulaCoron. AV fistulaSystemic AV fistula.Systemic AV fistula.Coarctation of the aortaCoarctation of the aorta
Peripheral PS.Peripheral PS.Anom. LCA from PA.Anom. LCA from PA.AP window.AP window.MS with small ASD.MS with small ASD.Venous hum.Venous hum.Post traumatic.Post traumatic.
Continuous MurmursContinuous Murmurs
Cyanotic patientsCyanotic patients :- :- Bronchial collat. in TOF physiologyBronchial collat. in TOF physiology PDA in TOF physiologyPDA in TOF physiology TAPVCTAPVC Pulm. AV fistulaPulm. AV fistula PTAPTA Surgical shuntsSurgical shunts
Continuous MurmursContinuous Murmurs
T.O.F. PhysiologyT.O.F. Physiology :- :- Fallot’s tetralogyFallot’s tetralogy Tricuspid atresiaTricuspid atresia DORV with VSD & PS/PADORV with VSD & PS/PA TGA with VSD & PS/PATGA with VSD & PS/PA Single vent. With PS / PASingle vent. With PS / PA Miscellaneous malpositions with Miscellaneous malpositions with
VSD & PS/PA.VSD & PS/PA.
Continuous MurmursContinuous MurmursPDAPDA :- :- Max intensity ULSB. Thrill Max intensity ULSB. Thrill ±± Systolic component louder, harsh broken Systolic component louder, harsh broken
into multiple clicks.into multiple clicks. Diastolic component smooth and Diastolic component smooth and
decrescendo.decrescendo. Hollow characterHollow character Peaks at S2.Peaks at S2. With PAH the diastolic component With PAH the diastolic component
becomes shorter and may disappear .becomes shorter and may disappear . May be palpable as systolic or cont. thrill.May be palpable as systolic or cont. thrill.
S1 S2 S1
CM
x
Continuous MurmursContinuous Murmurs
Sinus of Valsalva fistulaSinus of Valsalva fistula :- :- Palpable as cont. thrill.Palpable as cont. thrill. Loud grade V / VI.Loud grade V / VI. May mask both S1 and S2May mask both S1 and S2 Louder systolic component if VSD is Louder systolic component if VSD is
present.present. Louder diastolic component if AR is Louder diastolic component if AR is
present.present. Both VSD and AR may be present.Both VSD and AR may be present.
Continuous MurmursContinuous Murmurs
Sinus of Valsalva fistulaSinus of Valsalva fistula :- :- Louder at RSB if in RA.Louder at RSB if in RA. Louder at MLSB if in RV.Louder at MLSB if in RV.
Systolic component may be softer.Systolic component may be softer.
S1 S2 S1
CM
Continuous MurmursContinuous Murmurs
Coron. AV fistulaeCoron. AV fistulae :- :- Relatively uncommon.Relatively uncommon. CM – 2 to 6 in intensity.CM – 2 to 6 in intensity. Mid to lower L, RSB.Mid to lower L, RSB. Shunt size usually small.Shunt size usually small. Myocard. isch. uncommonMyocard. isch. uncommon
Continuous MurmursContinuous Murmurs
Syst. AV fistulaeSyst. AV fistulae :- :- Intra cranial, intrahepatic, chest wall, Intra cranial, intrahepatic, chest wall,
abdomen, extremities.abdomen, extremities. CM. grade 2 to 4, midsystolic and CM. grade 2 to 4, midsystolic and
diastolic peaks.diastolic peaks. Depending on size of shunt; features Depending on size of shunt; features
of (a) aortic runoff (b) hyperkinetic of (a) aortic runoff (b) hyperkinetic circ state (c) circ state (c) syst. ven. pr. (d) CCF syst. ven. pr. (d) CCF specially neonates.specially neonates.
Continuous MurmursContinuous Murmurs
Coarctation of the AoCoarctation of the Ao :- :- Systolic hypertension arms.Systolic hypertension arms.
Systolic pr. diff between upper Systolic pr. diff between upper and lower segment – ejection and lower segment – ejection syst. m.syst. m.
Identical diast. pr. – no diast. m.Identical diast. pr. – no diast. m.
Cont. murmurs rare.Cont. murmurs rare.
Continuous MurmursContinuous Murmurs
Peripheral PSPeripheral PS :- :-
Systolic gradient between proximal and Systolic gradient between proximal and distal segments – ejection syst. m.distal segments – ejection syst. m.
No diastolic gradientNo diastolic gradient- no diastol. or CM.- no diastol. or CM.
Rarely a diastolic gradient may be present Rarely a diastolic gradient may be present & CM.& CM.
Acyanotic; PAH Acyanotic; PAH ±±
Continuous MurmursContinuous MurmursALCAPAALCAPA :- :-
High PA pr. perfuses LCA at birth.High PA pr. perfuses LCA at birth.
↓ ↓ PVR by 3-6 wks - myocard. ischaemia - PVR by 3-6 wks - myocard. ischaemia - anterolat. M.I.anterolat. M.I.
Rarely good collaterals from RCA to LCA.Rarely good collaterals from RCA to LCA.- Present in childhood or later as a CM with - Present in childhood or later as a CM with
small L to R shunt.small L to R shunt.
Dx. : Echo; RCA angio.Dx. : Echo; RCA angio.
Continuous MurmursContinuous Murmurs
AP WindowAP Window :- :- Relatively rare anomaly.Relatively rare anomaly. Usually large defects hence no Usually large defects hence no
CM.CM. 1-2% small. Atypical loud CM at 2 1-2% small. Atypical loud CM at 2
or 3 LICS.or 3 LICS. Dx. Difficult. Site of m. unusual for Dx. Difficult. Site of m. unusual for
PDA.PDA.
Continuous MurmursContinuous Murmurs
MS with small ASDMS with small ASD :- :- Findings of MS.Findings of MS. Loud venous hum at ¾ RSB.Loud venous hum at ¾ RSB. Louder in systole and expiration.Louder in systole and expiration. ? Is frequency higher.? Is frequency higher.
Continuous MurmursContinuous Murmurs
Venous humVenous hum :- :- Common upto 6 to 8 yrs.Common upto 6 to 8 yrs. RSB, above clavicle, child RSB, above clavicle, child
sitting up.sitting up. Intensity Intensity with inspiration. with inspiration. May disappear : head to left, May disappear : head to left,
pressure above clavicle, lying pressure above clavicle, lying down.down.
Continuous MurmursContinuous Murmurs
TOF PhysiologyTOF Physiology : : Severe obstr. Or PA.Severe obstr. Or PA. Bronchial or Aorto pulm. collaterals Bronchial or Aorto pulm. collaterals
perfuse PA.perfuse PA. Soft venous hum like CM.Soft venous hum like CM.
- Chest wall, interscapular area.- Chest wall, interscapular area. Large flow – louder m.Large flow – louder m.
- Mild cyanosis, LVE, Ao. runoff - Mild cyanosis, LVE, Ao. runoff ±.±. If PDA – usual site, m. can be atypical.If PDA – usual site, m. can be atypical.
Continuous MurmursContinuous Murmurs
TAPVCTAPVC :- :- CM : SSN, upper RSB, CM : SSN, upper RSB, flow, no obstr. flow, no obstr. Infradiaphragmatic : CM in Infradiaphragmatic : CM in
epigastrium, over the liver.epigastrium, over the liver. Obstr. site of PV entry to syst. V. / RA.Obstr. site of PV entry to syst. V. / RA. Features of severe PAH less common Features of severe PAH less common
with CM.with CM.
Continuous MurmursContinuous Murmurs
Pulm. AVFPulm. AVF :- :- Unexplained cyanosis.Unexplained cyanosis. Hemoptysis, embolism, brain Hemoptysis, embolism, brain
abscess.abscess. No CE, S1 & S2 normal, no m.No CE, S1 & S2 normal, no m. ECG normal.ECG normal. Cont. m. over chest wall.Cont. m. over chest wall. Chest x-ray may identify.Chest x-ray may identify. Contrast : left brachial inj.Contrast : left brachial inj.
Continuous MurmursContinuous Murmurs
Persistent truncusPersistent truncus :- :- Ejection syst. m. ends before A2.Ejection syst. m. ends before A2. Truncal regurg. m. starts with A2.Truncal regurg. m. starts with A2. Usually to & fro m.Usually to & fro m. Rarely PA osteal stenosis may result in Rarely PA osteal stenosis may result in
CM.CM. Dx. : Echo DopplerDx. : Echo Doppler
Continuous MurmursContinuous Murmurs
VSD with ARVSD with AR :- :- Pansyst. m masks S1 and S2.Pansyst. m masks S1 and S2. AR m. starts with A2.AR m. starts with A2. No gap at upper LSB.No gap at upper LSB. Below Lt. clavicle m. character → to Below Lt. clavicle m. character → to
and fro.and fro.
Continuous MurmursContinuous Murmurs
AS with ARAS with AR :- to & fro. m. :- to & fro. m. AS m. ends before A2.AS m. ends before A2. AR m starts from A2.AR m starts from A2. Gap easily appreciable should Gap easily appreciable should
not be mistaken for a CM.not be mistaken for a CM.
S1 S2 S1
X ESM ARM
Continuous MurmursContinuous Murmurs
Acyanotic patientsAcyanotic patients : Physiol. effects : Physiol. effects L L → R shunt→ R shunt Vol overload of circ. Vol overload of circ. Hyperkinetic circ. State Hyperkinetic circ. State ↓ SVR, ↓ SVR, CO, CO,
HR and SVHR and SV Plasma vol.Plasma vol. Aortic runoff.Aortic runoff.
Continuous MurmursContinuous Murmurs
Acyanotic patientsAcyanotic patients : Physiol. effects : Physiol. effects syst. ven. pr.syst. ven. pr. M VOM VO22.. Ao diast. Pr.Ao diast. Pr. Myocard.Myocard. LV edp.LV edp. IschaemiaIschaemia diast. Filling timediast. Filling time
Continuous MurmursContinuous Murmurs
Cyanotic patientsCyanotic patients : Physiol. effects : Physiol. effects Depend on anomalyDepend on anomaly Pulm. AVFPulm. AVF
- - PVR in fistula PVR in fistula
- - PVR non affected area PVR non affected area
- R - R → L shunt – cyanosis→ L shunt – cyanosis
- Potential for paradox embolism, - Potential for paradox embolism, brain abscess, hemoptysis. brain abscess, hemoptysis.
S1 S2 S1
S1 S2 S1
S1 S2 S1
X ESM ARM
CM
CM
top related