Regurgitant Systolic Murmurs Chapter 15 Are G. Talking, MD, FACC Instructor Patricia L. Thomas, MBA, RCIS

Outline Mitral Regurgitation Tricuspid Regurgitation Ventricular Septal Defect Patent Ductus Arterious Acute Ventricular Septal Perforation Papillary Muscle Rupture Mitral Valve Prolapse Syndrome

Introduction Regurgitant Murmurs are caused by retrograde flow across AV valves TR heard at the lower left sternal border MR heard at the apex Holosystolic Murmurs suggest MR, TR, VSD’s

Chronic Mitral Regurgitation Continues as long as LV pressure > that of the enlarged LA Begins at S1 and extend through S2 Large high pitched, blowing holosystolic/pansystolic murmur

Acute Mitral Regurgitation Loud Grade IV or >, diamond shaped Pressure in the normal nondilated LA increases rapidly because of regurgitant flow in early systole and = LV pressure in late systole

Mitral Regurgitation Causes Rheumatic Heart Disease Papillary Muscle Dysfunction Mitral Valve Prolapse Rupture Chordae Tendineae Calcified mitral Annulus LV Dilatation

Tricuspid Regurgitation The holosystolic murmur of MR engulfs A2 but stops before P2 whereas the murmur of TR persists through and engulfs P2 Increases with inspiration (Carvallo sign) & does not radiate well to the axillary region

Mild TR Infective Endocarditis seen with IV drug abuse may be mid-systolic of low intensity, heart only with inspiration S4 may be present Advance TR May not increase with inspiration or may be absent Tricuspid honk or whoop (highly musical)

Causes Tricuspid Insufficiency is commonly secondary to dilatation of the right ventricle Severe Right Heart Failure secondary to mitral stenosis Pulmonary Heart Disease with pulmonary hypertension Congenital deformity (Epstein's Anomaly), Rheumatic Valve disease, or Infective Endocarditis Listen with the diaphragm of the stethoscope along the lower left sternal border (third interspace)

Ventricular Septal Defect Holosystolic, loud, & harsh; S2 is loud & widely split; possible palpable thrill Begins with ventricular systole S1, when the rise in LV pressure exceeds that of the RV & continues until S2 when left ventricular pressure falls Listen with the diaphragm of the stethoscope from the mid-to lower left sternal border

Patent Ductus Arteriosus Acute Ventricular Septal Perforation Continuous murmur Acute Ventricular Septal Perforation Caused by acute MI Loud short systolic murmur, grade IV Listen with diaphragm of stethoscope Papillary Muscle Rupture mid-to late systolic murmur, thrill Listen with diaphragm for the stethoscope

Mitral Valve Prolapse Syndrome Mid-to-late systolic, late systolic, or holosystolic Moderate Prolapse 1/3 or ½ into systole & increases its intensity until A2 Valve is competent in early systole & prolapse in LA in late systole Severe Prolapse Loud S1, holosystolic murmur Fusion of a click with S1, Sound is louder Click In < ½ of patients marks onset of the murmur “click murmur syndrome” Cause Mitral insufficiency

THE END OF CHAPTER 15 Tilkian, Ara MD Understanding Heart Sounds and Murmurs, Fourth Edition, W.B. Sunders Company. 2002, pp. 180-196