diastolic murmurs

Diastolic Murmurs

Dr Muhammed AslamJunior Resident

Pulmonary MedicineACME Pariyaram

Presented at Sahakarana Hrudayalaya

Diastolic Murmurs

• Always signify an abnormal cvs - structurally or functionally

• Not graded by intensity but by their length• Thrill additionally mentioned

Classification

A) Those arising at the AV valves1.Mid diastolic2.Presystolic3.CombinedB) Those arising at semilunar valves1.Early diastolic2.Mid diastolic sounding early diastolic

Diastolic murmurs at AV valves

Mechanism and Causes of Diastolic Murmurs at Apex

A- Narrowing of mitral valve or left ventricular inflow1.Mitral stenosis2.Left atrial myxoma3.Cor-triatrium4.Constriction of AV groove as in constrictive

pericarditis5.Hypertrophic cardiomyopathy (narrow inflow

cavity


B.Increased flow across AV valve1.Left to right shunts (post tricuspid shunts)

(VSD,Ductus,systemic artero venous fistula,RSOV in to right ventricle,aotopulmonary window/fistula, Truncus Arteriosus)

2.Mitral Regurgitation (severe)3.Hyperkinetics circulatory

states(anemia,thyrotoxicosis,pregnancy)4.Chronic complete heart block


C. Mechanisms that interfere with mitral valve openingAustin flint murmur with severe aortic regurgitation

D.Ventricular aneurysm with a narrow neck

E.Murmurs arising some where else but heard at apex1.Aortic regurgitation2.Tricuspid stenosis3. Tricuspid flow murmur of ASD4.Ebstien’s anomaly

Mitral Stenosis murmur featuresFeatures DescriptionSite of best audibility apex

Timing Mid-diastolic/ pre systolic

Selective conduction Localised to apex

character Rough, rumbling (low pitched)

length Short/moderate/long

respiration Increases during expiration

posture >left lateral , < standing

Amyl nitrate inhalation increases

Isotonic exercise increases

Isometric hand grip variable

Mechanism of MDM in MS

• As the mitral valve become stenotic the left atrial pressure increases with a gradient between left atrium and left ventricle in diastole. The opening snap result from abrupt opening of the doming mitrale valve. As the atrial contraction contributes to increased gradient in pre systole, there is pre systolic accentuation of murmur

Mechanism of pre systolic murmur

• Atrial contraction• Persistent atrio ventricular gradient• Left ventricular contraction in presystole

reducing mitral funnel

Absence of presystolic murmur in MS

• Atrial fibrillation• Mild MS• Prolonged PR interval• Bradycardia• Elevated LVEDP (left ventricular

dysfunction)

Severity of MS : Auscultatory features

Severity of ms S2-os interval in second

features

mild 0.08-0.12 Short mdm/ or pre systolic murmur or murmur may appear with exercise

moderate 0.06-0.08 MDM + pre systolic murmur with a gap between them.Varying degree of MDM in atrial fibrillation

sever 0.04-0.06 MDM + pre systolic murmur with no gap.pre systolic murmur with atrial fibrillation

• With a HR 70-90/min a normal cardiac out put and a normal left ventricular end diastolic pressures , the longer murmur the more severe the stenosis.

Mechanism influencing the length of murmur in MS

1) Cardiac output2) Heart Rate3) Left atrial pressure4) Left ventricular end diastolic pressure5) Heart Rhythm When alteration in any of the above features occur, the

murmur of Mitral stenosis should not be relied upon to assess the severity of mitral stenosis

Character of murmur

• Rough, rumbling (low pitched)• Non calcific valve – Very low frequency,

loud diastolic murmur with a thrill• Severe calcific valve – high frequency,

less intensity , no thrill• Heard with bell of diaphragm

Tricuspid diastolic murmursmechanism causesObstruction to rt ventricular inflow •Tricuspid valve stenosis

A-rheumaticB-congenitalC-carcinoid•Right atrial tumors- myxoma/secondary•Ebsteins anomaly

Increased flow across valve Pre tricuspid shuntsA-ASDB-TAPVCC-RSOV TO RAD-LV TO RA communicationsE-coronary artery to RA communicationF-Lutembachers syndromeG-partial anomalous venous connection

Tricuspid diastolic murmursmechanism causes

Interference with opening of TV Severe tricuspid regurgitationA-functionalB-organic

Murmur produced somewhere else but also heard at tricuspid area

•Severe TR with right sided Austin Flint murmur•MS•Pulmonary regurgitation•Aortic regurgitation

Murmurs mistaken for tricuspid diastolic murmur

•Normal pressure pulmonary incompetence•Pericardial rub•Right sided s4 may sound like pre systolic murmur

The murmur of tricuspid stenosisfeatures descriptions

Site of best audibility Tricuspid area

timing Pre systolic with or without Mid diastolic

length Short/moderate/long

character Rough/rumbling

Selective conduction Localised to tricuspid area

Relation to physiological act•Respiration•Posture

•Rapid deep breathing

•Increased during inspiration•Increase in supine , passive leg raising

•increases

• Length of murmur is directly related to the severity of tricuspid stenosis

• Significant tricuspid stenosis with shorter or no murmur : causes

1)Rheumatic TS with accompanying MS, severe PAH ,Increased Right ventricular end diastolic pressure

2) Diuretic therapy in TS 3) Atrial fibrillation ( absent pre systolic murmur) 4) Ebstein’s Anomaly of tricuspid valve

Other mid diastolic murmurs at the AV valve

1) Mid diastolic murmur of MR• Mid diastolic and shorter• Associated with s3• Never pre systolic• Suggest severe MR• Favors rheumatic MR• First sound is usually diminished or absent

2.MDM of L to R shunt

Tricuspid flow murmur in ASD• Best heard at lower left sternal border but may be

heard at apex or upper left sternal border• Only mid diastolic with no presystolic murmur• Relatively soft or medium frequency• No significant change with respiration• Indicate pulmonary flow to be twice the systemic flow or

higher

Causes of Tricuspid flow murmur

A)Left to right shunts(pre tricuspid)1.ASD 2.PAVC3.RSOV4.Coronary cameral fistula in to rt atrium5.Left ventricular right atrial communication

(Gerbodes defect)

Causes of Tricuspid flow murmur

B) Admixture lesions ( Cyanotic heart disease)

1.TAPVC2.Single atrium3.Hypoplastic left heart syndrome ( mitral atresia)C)Severe tricuspid regurgitationsD)The right sided Austin-Flint murmur in

severe functional pulmonary regurgitation

Causes of mitral flow murmurs

A) Left to right shunts (post tricuspid shunts)1.VSD2.PDA3.Aorto pulmonary window4.Systemic arteriovenous fistula


B) Admixture lesion (cyanotic heart disease)i) Increased pulmonary flow1.DORV2.SINGLE VENTRICLE3.TRUNCUS ARTERIOSUS4.TRICUSPID ATRESIA WITH LARGE VSD BUT NO PS5.EXTENSIVE BRONCHOPULMONARY COLLATERALS IN PULMONARY

ATRESIA OR ANY CYANOTIC HEART DISEASE WITH DIMINISHED BLOOD FLOW

6.SYSTEMIC TO PULMONARY ARTERY SHUNTS

ii) Diminished pulmonary flowTRICUSPID ATRESIA WITH PULMONIC STENOSIS


C. Hyperkinetic circulatory states1.Severe anemia2.Thyrotoxicosis

D. Severe mitral regurgitation

Austin Flint Murmur• In moderate to severe AR• Mid diastolic and/or presystolic• Low pitched best heard with bell• Heavy jet of aortic regurgitation impinging on the

anterior leaflet of mitral valve preventing adequate opening of the valve and creating turbulence to flow from left atrium to ventricle in diastole

• with premature closure of mitral valve as in free severe AR or a/c AR the pre systolic murmur does not occur.

Austin Flint Murmur

• With isometric hand grip, the degree of aortic regurgitation increases due to elevated peripheral vascular resistance and flint murmur increases.

• With administration of vaso dilators , the murmur decreases or disappear due to reduction in severity of AR

Austin Flint vs MSFeatures Austin Flint MS

1.Diastolic Thrill Rare Common

2.Amyl Nitrate Inhalation ↓ ↑

Isometric hand grip / vasopressors

↑ variable

s1 ↓/N ↑

OS - +

LV s3 May occurs never

Rhythm Sinus rhythm AF is common

Auscultatory phenomena simulating mid- diastolic murmurs

1. S3 as MDM2. S4 as presystolic murmur3. S3+s4 together as MDM4. Pericardial knock of constrictive

pericarditis5. Pericardial rub6. The early diastolic murmur of AR at apex

Other Mid Diastolic Murmur

• Carey Coomb’s murmurs

– Acute rheumatic fever, mitral valve structures acutely inflamed with some thickening and edema turbulence of flow during the rapid filling phase + moderate MR [increased mitral inflow in diastole]

– Low pitched short MDM.– Distinguished from MS MDM by the absence of opening snap before

the murmur– good evidence of active carditis

Early diastolic murmur

AR murmur• Timing - Early diastolic• Site of best audibility – best heard along left sternal

border, but is also well heard at right 2nd space and apex.

Left sternal border murmur of AR causes

Right sternal border murmur of AR causes

1. Rheumatic heart disease 2. Congenital bicuspid valve3. IE4. AR in association with valvular

AS or subvalvular fixed AS5. Prosthetic AR

1. Syphilis2. Marfan syndrome3. Ankylosing spondylitis4. Rheumatoid arthritis5. AR associated with TOF or VSD

AR murmur

• Character- high frequency / soft / blowing/ musical

• Thrill is rare• Length of the murmur correlates with

severity

AR murmur

Causes of AR with short or no murmur1. a/c AR2. LVF3. Tachycardia4. Hypotension5. Vasodilators6. Pregnancy

Relation to physiological act

• Respiration and posture – best heard in sitting ( or standing ) leaning forward , held in expiration

• Isometric hand grip - ↑• Vasopressor - ↑• Vasodilator - ↓• Squatting - ↑

maneuver mechanisms

Sitting,leaning forward,held expiration,diaphragm firmly applied to chest

•Aorta nearer to chest•Non interference with the noise of breathing•Improved quality of diaphragm to appreciate the high frequency murmur

Prone position Aorta nearer to chest

Prompt squatting Increased systemic vascular resistance

Isometric hand grip As above

vasopressors •Increased systemic resistance

Auscultatory events or murmurs simulating ARAuscultatory event /murmur Differentiating featurePR with PAH (Graham Steel murmur) •Not audible at Rt side of sternum and

apex•May ↑ with inspiration•↓ with standing / inspiration

MDM of severe MS at apex and occasionally along LSB

Low frequency , better heard with bell

MDM of severe MR when heard along left sternal border

As above

MDM of TS •↓ with sitting , standing , during expiration•↑ with inspiration , supine position•Better heard with bell•Prominent a wave with elevated JVP

Pericardial friction rub when high frequency or musical

•Changes with posture / respiration•Never heard to rt of sternum

Cole- Cecil murmur• AR murmur in left axilla due to higher position of apex

Murmur of Pulmonary Regurgitation with PAH(Graham – Steell murmur)

• Timing – early diastolic• Length- very short to pan diastolic Length of murmur reflects the duration of

pressure difference between pulmonary artery and right ventricle in diastole

• Site of best audibility – pulmonary area• Character – high pitched (PR with no PAH

is low frequency )• Conduction – left sternal border 3 rd and 4

th spaces

Relation to physiological act

• Respiration – may incrs during inspiration-mainly in PR with no PAH

• Posture – better heard in supine posture ,passive leg raising

• No influence for isometric hand grip/ vasopressors/amyl nitrite inhalation

PR with normal pressureFeature Description

Timing Mid - diastolic

length Short , never pan diastolic

Site of best audibility Pulmonary area

character Low frequency , rumbling

conduction Localised to pulmonary area , may be heard along left sternal border

Relation to physiological act1. Posture

2. Respiration

• Incrs during supine / passive leg raising .Decrs with standing

• Incrs with inspiration.Decrs with exprn

Other diastolic murmurs

• Cabot– Locke Murmur- [Diastolic Flow murmur] - in severe anemia

– The Cabot–Locke murmur is a diastolic murmur that sounds similar to aortic insufficiency but does not have a decrescendo; it is heard best at the left sternal border. [High flow thru coronary vessels, LMCA, LAD]

– The murmur resolves with treatment of anaemia.

• Dock’s murmur – diastolic crescendo-decrescendo, with late accentuation, [consistent

with blood flow through the coronary] in a sharply localized area, 4 cm left of the sternum in the 3LICS, detectable only when the patient was sitting upright.

– Due to stenosis of LAD

Other diastolic murmurs

• Key–Hodgkin murmur – EDM of AR; it has a raspy quality, [sound of a saw cutting through

wood]. Hodgkin correlated the murmur with retroversion of the aortic valve leaflets in syphilitic disease.

• Rytand’s murmur– Late diastolic murmur in complete heart block

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