1. Murmurs and Myocardial Sounds…Making Sense of the Madness
Sara G. Tariq, M.D.
August, 2012

2. Goals Know how we classify murmurs Systolic Diastolic Both
Crescendo-decrescendo
Aortic stenosis, pulmonic stenosis, or “innocent” murmur
Holosystolic
Mitral regurg, tricuspid regurg or VSD
Late Systolic - MVP
Diastolic
Aortic regurgitation, pulmonic regurgitation
Stenosis of mitral or tricuspid
Both
Patent Ductus Arteriosus

3. Goals Know the significance of rubs
Know the significance of extra sounds
Split S2 (varies vs split) S3 S4

4. What are murmurs? Sounds
Murmurs exist because of turbulent blood flow or increased velocity of blood flow across an orifice (a valve)
Usually 3 different kinds of sounds
Holosystolic, crescendo-decrescendo or decrescendo,

5. Does sound matter?
Most murmurs will worsen with smaller orifice size—so 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.

6. Grading the Sound
I-faintest murmur that can be heard (with difficulty)
II- murmur is also a faint murmur but can be identified immediately
III- moderately loud
IV- loud with a palpable thrill
V- very loud, but still need stethoscope
VI- loudest and can be heard without stethoscope

8. S1 and S2
Closing of the mitral (tricuspid, too) and aortic (pulmonic, too) valves
Usually very crisp
You should hear S1 loudest at mitral area
You should hear S2 loudest at aortic area

9. Where do you hear murmurs?
RUSB= (may radiate to neck)
LUSB=Pulmonic (may radiate to back)
LLSB=Tricuspid (usually doesn’t radiate)
Apex=Mitral (may radiate to axilla)

10. Systolic murmurs “swooshing” sounds
Occur right after S1 (closing of mitral valve) and before S2 (closing aortic v)
Causes:
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 isn’t (mitral reg)
A hole exists where it shouldn’t in the ventricular septum and blood crosses from high pressure side to low pressure side (VSD)

11. Mitral regurgitation

12. Mitral regurgitation
Mitral valve is incompetent and does not close properly (door won’t close)
Result: abnormal leaking of blood from the LV, through the mitral valve, and into the left atrium
Causes: myxomatous degeneration, MI, dilated LV
Sound: holosystolic (swoosh lasts throughout systole) radiates to axilla

13. Mitral and tricuspid valves – like a parachute

14. Systolic Murmurs Mitral Regurgitation (apex) Systolic murmur
Radiates to axilla S1 S2 S1

15. 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

16. Aortic Stenosis

17. Aortic stenosis The aortic valve narrows
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
Causes: congenitally bicuspid valve, wear and tear from age, Rheumatic fever
Sound: crescendo-decrescendo murmur in systole, radiates to carotids

18. Physical Exam: Cardiac
RUSB with diaphragm; radiates to carotids bilaterally S1 S2 S1

19. VSD

20. VSD Congenital – hole in septum Left heart pressures>right heart
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
Only difference is that it is usually over the sternal border

21. Systolic Continuous Ventricular Septal Defect
Arteriovenous connections (PDA)

22. “Innocent murmur” AKA “physiologic murmur” Doesn’t radiate
Occurs NOT from a structural problem in the heart but from something outside the heart
Hyperthyroidism, anemia

23. Systolic Murmurs Innocent murmurs
Usually ‘diamond shaped’, brief, little radiation
Common in children and young adults
ALWAYS: systolic, < III/VI intensity, other heart sounds and pulses are normal S1 S2 S1

24. Diastolic murmurs= really bad
Same “swoosh” but at a different time
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)
Ventricular outflow tract can not stay shut (aortic regurg)

25. Aortic Regurgitation

26. Aortic regurg Aortic valve can not close fully
Some blood that should go forward to the body now comes back into the heart
Causes:congenitally bicuspid valve
You hear the turbulence in diastole after aortic valve should have fully closed (after S2)

28. Diastolic Murmurs Aortic Regurgitation (Upper sternal)
radiates inferiorly
best heard with patient sitting up and leaning forward (in expiration) S1 S2 S1

29. Mitral stenosis

30. Mitral stenosis
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
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 doesn’t radiate

31. Patent Ductus Arteriosis (PDA)
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 can put strain on the heart and increase blood pressure in the lung arteries.

32. PDA
Sounds like continuous machinery murmur throughout systole and diastole

33. Systolic Continuous Ventricular Septal Defect
Arteriovenous connections (PDA)

34. Split S2 Physiologically split S2 Fixed Split S2= ASD
Natural 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 valve
Fixed Split S2= ASD
Increase pulmonary blood flow from increased preload from L->R shunt of blood across ASD delays closure of pulmonic valve
This split doesn’t change with respiration b/c ASD is more hemodynamically significant than the small increase in volume of blood that results from inspiration

35. Split S2 Paradoxically Split S2 You have split S2 in EXPIRATION
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!!

36. S3
Only be heard with the bell, never with the diaphragm .This helps distinguish it clinically from a widely split S2.
Is heard after S2
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)

37. S4 Caused by blood entering a thickened, stiffened ventricle.
Comes just before S1 in the cardiac cycle
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)

38. Rubs Pericardial rub= pericarditis
This is a velcro sound that you can hear throughout the cardiac cycle
Pericarditis
Recent upper resp tract infection
Chest pain that is better with leaning forward and worse with lying down