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Slide 2 Murmurs and Myocardial SoundsMaking Sense of the Madness Sara G. Tariq, M.D. August, 2012 Slide 3 Goals Know how we classify murmurs Know how we classify murmurs SystolicSystolic Crescendo-decrescendo Crescendo-decrescendo Aortic stenosis, pulmonic stenosis, or innocent murmurAortic stenosis, pulmonic stenosis, or innocent murmur Holosystolic Holosystolic Mitral regurg, tricuspid regurg or VSDMitral regurg, tricuspid regurg or VSD Late Systolic - MVP Late Systolic - MVP DiastolicDiastolic Aortic regurgitation, pulmonic regurgitation Aortic regurgitation, pulmonic regurgitation Stenosis of mitral or tricuspid Stenosis of mitral or tricuspid BothBoth Patent Ductus Arteriosus Patent Ductus Arteriosus Slide 4 Goals Know the significance of rubs Know the significance of rubs Know the significance of extra sounds Know the significance of extra sounds Split S2 (varies vs split)Split S2 (varies vs split) S3S3 S4S4 Slide 5 What are murmurs? Sounds Sounds Murmurs exist because of turbulent blood flow or increased velocity of blood flow across an orifice (a valve) Murmurs exist because of turbulent blood flow or increased velocity of blood flow across an orifice (a valve) Usually 3 different kinds of sounds Usually 3 different kinds of sounds Holosystolic, crescendo-decrescendo or decrescendo,Holosystolic, crescendo-decrescendo or decrescendo, Slide 6 Does 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. 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. 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. Slide 7 Grading the Sound I-faintest murmur that can be heard (with difficulty) I-faintest murmur that can be heard (with difficulty) II- murmur is also a faint murmur but can be identified immediately II- murmur is also a faint murmur but can be identified immediately III- moderately loud III- moderately loud IV- loud with a palpable thrill IV- loud with a palpable thrill V- very loud, but still need stethoscope V- very loud, but still need stethoscope VI- loudest and can be heard without stethoscope VI- loudest and can be heard without stethoscope Slide 8 Slide 9 S1 and S2 Closing of the mitral (tricuspid, too) and aortic (pulmonic, too) valves Closing of the mitral (tricuspid, too) and aortic (pulmonic, too) valves Usually very crisp Usually very crisp You should hear S1 loudest at mitral area You should hear S1 loudest at mitral area You should hear S2 loudest at aortic area You should hear S2 loudest at aortic area Slide 10 Where do you hear murmurs? RUSB= (may radiate to neck)RUSB= (may radiate to neck) LUSB=Pulmonic (may radiate to back)LUSB=Pulmonic (may radiate to back) LLSB=Tricuspid (usually doesnt radiate)LLSB=Tricuspid (usually doesnt radiate) Apex=Mitral (may radiate to axilla)Apex=Mitral (may radiate to axilla) Slide 11 Systolic murmurs swooshing sounds swooshing sounds Occur right after S1 (closing of mitral valve) and before S2 (closing aortic v) Occur right after S1 (closing of mitral valve) and before S2 (closing aortic v) Causes: Causes: having trouble getting out of the ventricle through a tight door (aortic stenosis)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)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)A hole exists where it shouldnt in the ventricular septum and blood crosses from high pressure side to low pressure side (VSD) Slide 12 Mitral regurgitation Slide 13 Mitral valve is incompetent and does not close properly (door wont close) Mitral 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 Result: abnormal leaking of blood from the LV, through the mitral valve, and into the left atrium Causes: myxomatous degeneration, MI, dilated LV Causes: myxomatous degeneration, MI, dilated LV Sound: holosystolic (swoosh lasts throughout systole) radiates to axilla Sound: holosystolic (swoosh lasts throughout systole) radiates to axilla Slide 14 Mitral and tricuspid valves like a parachute Slide 15 Systolic Murmurs Mitral Regurgitation (apex) Mitral Regurgitation (apex) Systolic murmurSystolic murmur Radiates to axillaRadiates to axilla S1 S2 Slide 16 Mitral valve prolapse displacement of an abnormally thickened mitral valve leaflet that gets displaced into the atrium in systole Mid-systolic click with late systolic murmur You can get mitral regurg if severe Slide 17 Aortic Stenosis Slide 18 Aortic stenosis The aortic valve narrows The aortic valve narrows Creates turbulent blood flow across the narrowed valve Creates turbulent blood flow across the narrowed valve Result- the heart has to work hard by creating pressure to get blood across the stenotic valve Result- the heart has to work hard by creating pressure to get blood across the stenotic valve Causes: congenitally bicuspid valve, wear and tear from age, Rheumatic fever Causes: congenitally bicuspid valve, wear and tear from age, Rheumatic fever Sound: crescendo-decrescendo murmur in systole, radiates to carotids Sound: crescendo-decrescendo murmur in systole, radiates to carotids Slide 19 Physical Exam: Cardiac RUSB with diaphragm; radiates to carotids bilaterally RUSB with diaphragm; radiates to carotids bilaterally S1 S2 Slide 20 VSD Slide 21 VSD Congenital hole in septum Congenital hole in septum Left heart pressures>right heart Left heart pressures>right heart So in systole, when heart contracts, the blood in the left goes across the window into the right side So in systole, when heart contracts, the blood in the left goes across the window into the right side Holosystolic murmur, just like mitral regurgitation Holosystolic murmur, just like mitral regurgitation Only difference is that it is usually over the sternal border Only difference is that it is usually over the sternal border Slide 22 Systolic Systolic Ventricular Septal DefectVentricular Septal Defect Continuous Continuous Arteriovenous connections (PDA)Arteriovenous connections (PDA) Slide 23 Innocent murmur AKA physiologic murmur AKA physiologic murmur Doesnt radiate Doesnt radiate Occurs NOT from a structural problem in the heart but from something outside the heart Occurs NOT from a structural problem in the heart but from something outside the heart Hyperthyroidism, anemia Hyperthyroidism, anemia Slide 24 Systolic Murmurs Innocent murmurs Innocent murmurs Usually diamond shaped, brief, little radiationUsually diamond shaped, brief, little radiation Common in children and young adultsCommon in children and young adults ALWAYS: systolic, < III/VI intensity, other heart sounds and pulses are normalALWAYS: systolic, < III/VI intensity, other heart sounds and pulses are normal S1 S2 Slide 25 Diastolic murmurs= really bad Same swoosh but at a different time Same swoosh but at a different time You hear it right after S2 and before S1 You hear it right after S2 and before S1 Blood is having trouble leaving the atrium to the ventricle b/c door is partly shut (mitral stenosis) Blood 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) Ventricular outflow tract can not stay shut (aortic regurg) Slide 26 Aortic Regurgitation Slide 27 Aortic regurg Aortic valve can not close fully Aortic valve can not close fully Some blood that should go forward to the body now comes back into the heart Some blood that should go forward to the body now comes back into the heart Causes:congenitally bicuspid valve Causes:congenitally bicuspid valve You hear the turbulence in diastole after aortic valve should have fully closed (after S2) You hear the turbulence in diastole after aortic valve should have fully closed (after S2) Slide 28 Slide 29 Diastolic Murmurs Aortic Regurgitation (Upper sternal) Aortic Regurgitation (Upper sternal) radiates inferiorlyradiates inferiorly best heard with patient sitting up and leaning forward (in expiration)best heard with patient sitting up and leaning forward (in expiration) S1 S2 Slide 30 Mitral stenosis Slide 31 Mitral valve is tight so blood can not get out of the atrium Mitral valve is tight so blood can not get out of the atrium When the mitral valve area goes below 2 cm, the valve causes an impediment to the flow of blood into the left ventricle, creating a pressure gradient across the mitral valve. Pressure=turbulence=murmur When the mitral valve area goes below 2 cm, the valve causes an impediment to the flow of blood into the left ventricle, creating a pressure gradient across the mitral valve. Pressure=turbulence=murmur Causes: Rheumatic heart dz, damage from endocarditis Causes: Rheumatic heart dz, damage from endocarditis Sound: A mid-diastolic rumbling murmur will be heard after an opening snap. The murmur is best heard at the apical region and doesnt radiate Sound: A mid-diastolic rumbling murmur will be heard after an opening snap. The murmur is best heard at the apical region and doesnt radiatemurmur Slide 32 Patent Ductus Arteriosis (PDA) In some babies the ductus arteriosus remains patent (connects pulm a and aorta) 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 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. This can put strain on the heart and increase blood pressure in the lung arteries. Slide 33 PDA Sounds like continuous machinery murmur throughout systole and diastole Sounds like continuous machinery murmur throughout systole and diastole Slide 34 Systolic Systolic Ventricular Septal DefectVentricular Septal Defect Continuous Continuous Arteriovenous connections (PDA)Arteriovenous connections (PDA) Slide 35 Split S2 Physiologically split S2 Physiologically split S2 Natural delay in closure of pulmonic valveNatural delay in closure of pulmonic valve Why? 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 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= ASD Fixed Split S2= ASD Increase pulmonary blood flow from increased preload from L->R shunt of blood across ASD delays closure of pulmonic valveIncrease pulmonary blood flow from increased preload from L->R shunt of blood across ASD delays closure of pulmonic valve This split doesnt change with respiration b/c ASD is more hemodynamically significant than the small increase in volume of blood that results from inspirationThis split doesnt change with respiration b/c ASD is more hemodynamically significant than the small increase in volume of blood that results from inspiration Slide 36 Split S2 Paradoxically Split S2 Paradoxically Split S2 You have split S2 in EXPIRATIONYou have split S2 in EXPIRATION This can only happen when the aortic valve is delayed in closing.This 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!!A LBBB will cause delayed depolarization of the left ventricle and a slightly delayed closing of the aortic valve!! Slide 37 S3 Only be heard with the bell, never with the diaphragm.This helps distinguish it clinically from a widely split S2. Only be heard with the bell, never with the diaphragm.This helps distinguish it clinically from a widely split S2. Is heard after S2 Is heard after S2 It can be normal in children and young people if no other abnormalities are reported on exam. 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) 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) Slide 38 S4 Caused by blood entering a thickened, stiffened ventricle. Caused by blood entering a thickened, stiffened ventricle. Comes just before S1 in the cardiac cycle Comes just before S1 in the cardiac cycle Can be left or right sided Can be left or right sided Can occasionally be heard in athletes but more commonly found in ventricular hypertrophy states or infiltrative cardiomyopathies (amyloid etc) Can occasionally be heard in athletes but more commonly found in ventricular hypertrophy states or infiltrative cardiomyopathies (amyloid etc) Slide 39 Rubs Pericardial rub= pericarditis Pericardial rub= pericarditis This is a velcro sound that you can hear throughout the cardiac cycle This is a velcro sound that you can hear throughout the cardiac cycle Pericarditis Pericarditis Recent upper resp tract infectionRecent upper resp tract infection Chest pain that is better with leaning forward and worse with lying downChest pain that is better with leaning forward and worse with lying down Slide 40