1. Dynamic Auscultation behaviour and the intensity of the
Listening to the change in character,
behaviour and the intensity of the
heart sounds and murmurs to
physiological and pharmacological
maneuvers…….
“AUSCULTATE WITH ALTERED HEMODYNAMICS”

2. Dynamic Auscultation Source of murmur : Right Heart ~ Left Heart
Differentiate closely simulating murmurs
Outflow ~ Regurgitatnt murmur
Differentiate flow murmurs from those of structural deformity : Austin Flint ~ MS
Differentiate Dynamic from Fixed Obstructions

3. Maneuvres Postural change Supine / L Lateral Standing Squatting
PHYSI(OLOGI)CAL
Postural change
Supine / L Lateral
Standing
Squatting
Valsalva
Handgrip
Cycle length change
PHARMACOLOGICAL
Amyl nitrite
Phenylephrine

4. Position
Left lateral decubitus : Augments the murmur of MS, MR, Austin Flint, MVP & S1, LV S3 & S4
Sitting & Leaning forward : ↑ AR murmur
Sitting with arms raised above the head : ↑ AR
Knee chest position : AR, Pericardial Rub
Passive leg raising : ↑ VR >↑ Right Heart events

9. Respiration
Inspiration augments right sided events, as the venous return increases :
TR & TS , PR & PS murmurs ; RV S3,S4 & TV OS
S1 & S2 split widen.
Exception is PES – augmented in expiration
# Preferably quiet respiration
# Avoid apnea
# Listen the first few beats
# In erect posture if Venous pressure is high

10. Carvallo’s sign Inspiratory accentuation of TR murmur
Early systolic murmur > holosystolic
Blowing quality > musical
Absent in severe RV failure
associated TS is severe
If venous pressure is very high, listening in upright posture may help

11. Reversed Carvallo sign
HCM with RVO obstruction - ? ↑ VR > widened RVO

15. Respiration Left sided events are better heard in expiration
MR, MS, AS & AR murmurs
LV S3 & S4, Mitral OS
Click & murmur of MVP occur later
@ PV – LA gradient increases > ↑ LV filling
@ Lung overlap decreases
@ Apnea for faint AR murmur

18. Pms = mean systemic pressure; Ppc = pulmonary capillary hydrostatic pressure; Ppi = pulmonary interstitial hydrostatic pressure; Ptm = pulmonary capillary transmural pressure

20. Abrupt standing
S2 split which may be wide, may narrow down , while the fixed split may persist
A2 OS interval widens – differentiates from wide split of S2
All murmurs ( except MVP/HOCM) decrease
ESM of HOCM becomes louder and longer
Click occurs earlier, murmur becomes longer in MVP – loudness shows variable response

23. Isometric Hand Grip
HAND DYNAMOMETER

25. Physiological changesof
ISOMETRIC
HANDGRIP
EXERCISE

26. Isometric Hand Grip LV S3 & S4 get augmented
Murmurs of MR,AR,VSD intensify
Mitral stenotic murmur may augment
Systolic murmur of HOCM may diminish
Click & late sytolic murmur of MVP get delayed

30. Transient Arterial Occlusion

32. Squatting
Increased venous return and CO > augments most murmurs atleast initially (AS,PS,MR,AR,VSD) Right heart murmurs do so earlier
Increased ventricular volume > murmur of HOCM ↓ murmur of MVP ↓→
Ejection murmur of TOF ↑

34. P Hanson
Br HeartJ7 1995;74:154

35. Central Aortic Pressure
T Murakami
AHJ 2002; 15:986–988

36. Hemodynamics of Squatting
T Murakami AHJ 2002; 15:986–988

37. T Murakami
AHJ 2002; 15:986–988

40. Valsalva Maneuver S2 split narrows down, S3 & S4 diminish
Decreased venous return & CO, HR ↑; PP↓
S2 split narrows down, S3 & S4 diminish

41. Valsalva Maneuver
Reduces the intensity of all murmurs except that of HOCM & MVP
Murmur of HOCM intensifies as the LV cavity size decreases
Click occurs earlier, the murmur lengthens in MVP – may not intensify
During release, the intensity of right heart murmurs returns earlier - 1 to 3 vs 5 beats for left heart murmurs

42. VALSALVA STRAIN

43. ASD, HF, MS

45. Cycle Length Variation Post premature beat / Long cycle short cycle of AF
Post VPD / Long > Short cycle of AF :
Outflow murmurs ( AS/PS) accentuate
Regurgitant murmurs do not change

47. Aortic Stenosis HOCM

48. Amylnitrite Inhalation
< 30 secs : Systemic vasodilatation
30 – 60 secs : ↑ HR & CO
Augments S1, LV S3 & S4, TV & MV OS, murmurs of AS,PS,TR & HOCM
A2 – OS may widen
Diminishes the murmurs of MR, AR, VSD, PDA & Systemic AVF
Click & Murmur of MVP occur earlier

49. Amyl Nitrite Inhalation
Augments Diminishes
Aortic stenosis Mitral regurgitation
Pulmonary stenosis TOF
Tricuspid regurgitation Mitral regurgitation
Mitral stenosis Austin Flint
Pulmonary regurgitation Aortic Regurgitaation

50. Phenylephrine ↑ BP & SVR ↓ CO & HR – last for 3-5mts
Reduces intensity of S1, A2-OS may widen
Augments the murmurs of VSD, PDA, MR, AR, TOF, Systemic AVF
Diminishes AS, MS & functional murmurs
ESM of HOCM diminishes
Click & murmur of MVP get delayed

52. ↑Afterload,↑Preload,↓Contractility ↓Afterload,↓Preload,↑Contractility

54. Valslava

60. the caveats are……… Avoid dynamic auscultation in sick patients
When postures are changed, transition should be abrupt
Continuous auscultation is required, when maneuvres are being elicited
Concentrate on the first few cycles after maneuvres
Realize that each maneuvre induces more than one alterations in hemodynamics