1. Systolic Ejection Murmurs Chapter 14
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS

2. Outline Tetralogy of Fallot Outflow Tracts
Dilatation of the Proximal Pulmonary
Pulmonary Arterial Narrowing
Coarctation of the Aorta
Musical Murmurs
Outflow Tracts
Inflow Tracts
Inter-Ventricular Flow
Ejection Murmur
Classification of Ejection
Aortic Stenosis
Bicuspid Aortic Valve

3. Introduction
Levine stated, “Systolic noise with a duration longer than a heart sound.”
Result of turbulent blood flow across outflow tracts, ejection murmurs,inflow tract, and from ventricle to ventricle

4. Outflow Tracts/ Ejection Pathways
Left outflow tract
Left ventricle
Aortic valve
Aortic root
Ascending Aorta
Right outflow tract
Right ventricle
Pulmonary Valve
Main Pulmonary Artery

5. Causes of Abnormalities of Flow
Forward flow across normal outflow tracts
Forward flow across stenosed aortic or pulmonic outflow tracts
High flow across normal right or left ventricular outflow tracts
High flow across a regurgitant aortic or pulmonic valve without significant stenosis
Forward flow into a dilated great vessel

6. Inflow Tracts
The inflow tracts of the heart are the chambers that are open to tack other during diastolic filling.
Mitral valve is part of the left inflow tract
Tricuspid valve is part of the right inflow tract
Abnormalities are insufficiency/regurgitant related: rheumatic valvular disease, mitral valve prolapse, or papillary muscle dysfunction

7. Inter-Ventricular Flow
Small VSD results in turbulent blood flow from ventricular to ventricle

8. Ejection Murmur
Mixed frequencies and is moderate-to-marked crescendo-decrescendo
Caused by forward flow across the left or right outflow
Aortic stenosis & pulmonic stenosis

9. Classification of Ejection Murmurs
Early Systolic Ejection Murmur
Commonly heard in a small VSD without pulmonary hypertension, large VSD with pulmonary hypertension, septal perforation resulting from MI, acute severe mitral regurgitation
Mid-systolic Ejection Murmur
Long and is loudest in mid-systolic with the sound of S2 clearly audible & implies significant aortic or pulmonic outflow tract obstruction, TOF, dilatation of he proximal pulmonary artery or ASD

10. Aortic Stenosis Murmur is harsh, rough, & grunting
Degrees of Obstruction
Mild- softer, shorter & earlier-peaking systolic murmur
Severe-louder, longer, & late-peaking murmur
Causes
Result of congenital aortic valve disease, rheumatic fever (aortic & mitral valve involved), or degenerative calcification in elderly patients
Listen with the diaphragm of the stethoscope for maximal intensity at the second right intercostal space; listen at the apex & over the precordium, both clavicles, both carotids, & suprasternal notch

15. Pulmonic Valve Stenosis
Harsh systolic murmur,wide splitting of S2
Loudest in the 2nd & 3rd interspaces along the left sternal border (pulmonic area)
Palpable Thrill felt directed toward the left neck or clavicle
Murmur peaks in mid-systole with maximal ejection & produces a diamond shape on the phono.
Heard during expiration
Ejection sound heard over the pulmonary area
Sound caused by doming & abrupt arrest in motion of the stenotic PV

18. Tetralogy of Fallot Described by Fallot in 1888
VSD, Pulmonic Stenosis, Dextroposition of the aorta & RV hypertrophy
PS results of a fibromuscular ring below the PV in the RV out flow tract-infundibular
More severe the obstruction, the more blood is shunted RT to LT the VSD
Systolic thrill pulmonic with grade IV murmur

21. Coarctation of the Aorta
Grade II or III murmur
Heard posteriorly & over base of the heart
Hypertension in the arms, but not in the legs
Decreased or absent femoral arterial pulsation

23. Musical Murmurs
Caused by vibrating structure enve in the the absence of flow turbulence
Musical systolic murmurs
Cooing of a dove
Buzzing of a saw
Spinning of a top
Whistling
Systolic whoop
Precordial honk
Mitral valve prolapse can assume such a noise

24. THE END OF CHAPTER 14
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp