1. Presented at Sahakarana Hrudayalaya1
Diastolic Murmurs
Dr Muhammed Aslam
Junior Resident
Pulmonary Medicine
ACME Pariyaram
Presented at Sahakarana Hrudayalaya

2. Diastolic Murmurs
Always signify an abnormal cvs - structurally or functionally
Not graded by intensity but by their length
Thrill additionally mentioned

3. Classification A) Those arising at the AV valves 1.Mid diastolic
2.Presystolic
3.Combined
B) Those arising at semilunar valves
1.Early diastolic
2.Mid diastolic sounding early diastolic

5. Diastolic murmurs at AV valves

6. Mechanism and Causes of Diastolic Murmurs at Apex
A- Narrowing of mitral valve or left ventricular inflow
1.Mitral stenosis
2.Left atrial myxoma
3.Cor-triatrium
4.Constriction of AV groove as in constrictive pericarditis
5.Hypertrophic cardiomyopathy (narrow inflow cavity

7. Mechanism and Causes of Diastolic Murmurs at Apex
B.Increased flow across AV valve
1.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

8. Mechanism and Causes of Diastolic Murmurs at Apex
C. Mechanisms that interfere with mitral valve opening
Austin flint murmur with severe aortic regurgitation
D.Ventricular aneurysm with a narrow neck
E.Murmurs arising some where else but heard at apex
1.Aortic regurgitation
2.Tricuspid stenosis
3. Tricuspid flow murmur of ASD
4.Ebstien’s anomaly

9. Mitral Stenosis murmur features
Description
Site 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
Isometric hand grip
variable

10. 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

11. Mechanism of pre systolic murmur
Atrial contraction
Persistent atrio ventricular gradient
Left ventricular contraction in presystole reducing mitral funnel

12. Absence of presystolic murmur in MS
Atrial fibrillation
Mild MS
Prolonged PR interval
Bradycardia
Elevated LVEDP (left ventricular dysfunction)

13. Severity of MS : Auscultatory features
S2-os interval in second
features
mild
Short mdm/ or pre systolic murmur or murmur may appear with exercise
moderate
MDM + pre systolic murmur with a gap between them.
Varying degree of MDM in atrial fibrillation
sever
MDM + pre systolic murmur with no gap.pre systolic murmur with atrial fibrillation

14. 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.

15. Mechanism influencing the length of murmur in MS
Cardiac output
Heart Rate
Left atrial pressure
Left ventricular end diastolic pressure
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

16. 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

17. Tricuspid diastolic murmurs
1717
Tricuspid diastolic murmurs
mechanism
causes
Obstruction to rt ventricular inflow
Tricuspid valve stenosis
A-rheumatic
B-congenital
C-carcinoid
Right atrial tumors- myxoma/secondary
Ebsteins anomaly
Increased flow across valve
Pre tricuspid shunts
A-ASD
B-TAPVC
C-RSOV TO RA
D-LV TO RA communications
E-coronary artery to RA communication
F-Lutembachers syndrome
G-partial anomalous venous connection

18. Tricuspid diastolic murmurs
mechanism
causes
Interference with opening of TV
Severe tricuspid regurgitation
A-functional
B-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

19. The murmur of tricuspid stenosis
features
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

20. Significant tricuspid stenosis with shorter or no murmur : causes
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

21. Other mid diastolic murmurs at the AV valve
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

22. 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

23. Causes of Tricuspid flow murmur
A)Left to right shunts(pre tricuspid)
1.ASD
2.PAVC
3.RSOV
4.Coronary cameral fistula in to rt atrium
5.Left ventricular right atrial communication (Gerbodes defect)

24. Causes of Tricuspid flow murmur
B) Admixture lesions ( Cyanotic heart disease)
1.TAPVC
2.Single atrium
3.Hypoplastic left heart syndrome ( mitral atresia)
C)Severe tricuspid regurgitations
D)The right sided Austin-Flint murmur in severe functional pulmonary regurgitation

25. Causes of mitral flow murmurs
Left to right shunts (post tricuspid shunts)
1.VSD
2.PDA
3.Aorto pulmonary window
4.Systemic arteriovenous fistula

26. Causes of mitral flow murmurs
B) Admixture lesion (cyanotic heart disease)
Increased pulmonary flow
1.DORV
2.SINGLE VENTRICLE
3.TRUNCUS ARTERIOSUS
4.TRICUSPID ATRESIA WITH LARGE VSD BUT NO PS
5.EXTENSIVE BRONCHOPULMONARY COLLATERALS IN PULMONARY ATRESIA OR ANY CYANOTIC HEART DISEASE WITH DIMINISHED BLOOD FLOW
6.SYSTEMIC TO PULMONARY ARTERY SHUNTS
ii) Diminished pulmonary flow
TRICUSPID ATRESIA WITH PULMONIC STENOSIS

27. Causes of mitral flow murmurs
C. Hyperkinetic circulatory states
1.Severe anemia
2.Thyrotoxicosis
D. Severe mitral regurgitation

28. 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.

29. 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

30. Austin Flint vs MS Features 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

31. Auscultatory phenomena simulating mid- diastolic murmurs
S3 as MDM
S4 as presystolic murmur
S3+s4 together as MDM
Pericardial knock of constrictive pericarditis
Pericardial rub
The early diastolic murmur of AR at apex

32. 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

33. Early diastolic murmur

34. 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
Rheumatic heart disease
Congenital bicuspid valve IE
AR in association with valvular AS or subvalvular fixed AS
Prosthetic AR
Syphilis
Marfan syndrome
Ankylosing spondylitis
Rheumatoid arthritis
AR associated with TOF or VSD

35. AR murmur Character- high frequency / soft / blowing/ musical
Thrill is rare
Length of the murmur correlates with severity

36. AR murmur Causes of AR with short or no murmur a/c AR LVF Tachycardia
Hypotension
Vasodilators
Pregnancy

37. Relation to physiological act
Respiration and posture – best heard in sitting ( or standing ) leaning forward , held in expiration
Isometric hand grip - ↑
Vasopressor - ↑
Vasodilator - ↓
Squatting - ↑

38. 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
Prompt squatting
Increased systemic vascular resistance
Isometric hand grip
As above
vasopressors
Increased systemic resistance

39. Auscultatory events or murmurs simulating AR
Auscultatory event /murmur
Differentiating feature
PR 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

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

41. 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

42. 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

43. 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

44. PR with normal pressure
Feature
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 act
Posture
Respiration
Incrs during supine / passive leg raising .Decrs with standing
Incrs with inspiration.Decrs with exprn

45. 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

46. 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

47. THANK YOU !!!