Download - Heart sounds and murmur
Heart Sounds & Murmurs
Dr.Vitrag Shah
First year resident,MD Medicine
April-2012
GMC,Surat
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Different areas for auscultation of heart
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I. Auscultatory Valve Area
1. MV: apex, fifth left intercostal
space, medial to the
midclavicular line
2. PV: second left intercostal space
3. AV: second right intercostal space
4. AV2: left third intercostalspace(Neoaortic/Erb’s area)
5. TV: lower part of left sternal border
6. Other part
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Dr.Vitrag Shah - www.medicalgeek.com
Auscultatory order
ApexPV AV AV2 TV
Or
ApexTV AV2PV AV
Content of auscultation1. Heart rate
2. Heart rhythm
3. Heart sound
4. Heart murmurs
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Function of the valves Valves prevent the back flow of blood.
The papillary muscles will not close the valves,they will maintain the closure of the valves.
The importance of chordea tendinei attached to the papillary muscles is because during ventricular contraction the ventricle size decreases and the papillary muscle must contract to shorten the chordea tendinei to prevent the leakage of valves
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Heart sounds
The bell and diaphragm of the stethoscope accentuate sounds of different pitches. The bell emphasizes low-pitched sounds such as normal heart sounds and the diastolic murmur of mitral stenosis. The diaphragm filters these sounds and helps to identify high-pitched sounds such as the early diastolic murmur of aortic regurgitation or a pericardial friction rub.
Normal heart valves make a sound when they close but not when they open. The classic 'lub-dub' sounds are caused by closure of the atrioventricular (mitral and tricuspid) valves followed by the outlet (aortic and pulmonary) valves.
the first and second heart sounds
extra heart sounds (third and fourth, heard in diastole)
additional sounds, e.g. clicks and snaps
pericardial rubs
murmurs in systole and/or diastole.
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Cause of the heart sounds
Slapping of the valves leaflets is not enough to generate a heart sound.
The causes of the 1st heart sound:
During systole the AV valves are closed & blood tries to flow back to the atrium back bulging the AV valves. But the taut chordaetendinae stop the back bulging and causes the blood to flow forward.
This will cause vibration of the valves, blood & the walls of the ventricles which is presented as the 1st heart sound.
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The causes of the 2nd heart
sound:
During diastole, blood in the blood vessels
tries to flow back to the ventricles cause the
semilunar valves to bulge. But the elastic
recoil of the arteries cause the blood to
bounce forward which will vibrate the blood
the valves and the ventricle walls.
This is presented as the 2nd heart sound.
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Difference between the 1st and
2nd heart sounds
The 1st sound lasts longer because the AV valves are less taut than the semilunar valves which will enable them to vibrate for longer time.
The 2nd heart sound had higher frequency due to
The semilunar valves are more taut
The great elastic coefficient of the taut arteries which provides the principle vibrations of the 2nd heart sound
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First heart sound
The first heart sound (S1), 'lub', is caused by closure of the mitral and tricuspid valves at onset of ventricular systole and is best heard at the apex.
Components of S1
Mitral Valve Closure Best Heard: Apex
Tricuspid Valve Closure Best heard: Lower Left Sternal Boarder
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Abnormalities of intensity of the
first heart soundQuiet
Low cardiac output
Poor left ventricular function
Long P-R interval (first-degree heart block)
Rheumatic mitral regurgitation , Calcified MS
Loud
Increased cardiac output
Large stroke volume
Mitral stenosis
Short P-R interval
Atrial myxoma (rare)
Variable
Atrial fibrillation
Extrasystoles
Complete heart block Dr.Vitrag Shah - www.medicalgeek.com
S1
Wide Splitting
RBBB
PVC from Left Ventricle
Single Sound
Normal
LBBB
PVC from Right Ventricle
Paced Beats
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Second Heart Sound The second heart sound (S2), 'dub', is caused by closure of
the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge.
It is louder and higher-pitched than the first sound, and the aortic component is normally louder than the pulmonary one.
Physiological splitting of the second heart sound occurs because left ventricular contraction slightly precedes that of the right ventricle so that the aortic valve closes before the pulmonary valve.
This splitting increases at end-inspiration because the increased venous filling of the right ventricle further delays pulmonary valve closure.
This separation disappears on expiration.Splitting of the second sound is best heard at the left sternal edge.
On auscultation, you hear 'lub d/dub' (inspiration) 'lub-dub' (expiration).
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Abnormalities of the second heart sound Quiet
Low cardiac output
Calcific aortic stenosis
Aortic regurgitation
Loud
Systemic hypertension (aortic component)
Pulmonary hypertension (pulmonary component)
Split Widens in inspiration (enhanced physiological splitting):
Right bundle branch block
Pulmonary stenosis
Pulmonary hypertension
Ventricular septal defect
Fixed splitting (unaffected by respiration):
Atrial septal defect
Widens in expiration (reversed splitting):
Aortic stenosis
Hypertrophic cardiomyopathy
Left bundle branch block
Ventricular pacing
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Dr.Vitrag Shah - www.medicalgeek.com
Physiological splitting of S2
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Fixed splitting of S2
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Reversed splitting of S2
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Third heart sound
A third heart sound (S3) is a low-pitched early diastolic sound best heard with the bell at the apex. It coincides with rapid ventricular filling immediately after opening of the atrioventricular valves and is therefore heard after the second as 'lub-dub-dum'.
0.12~0.18'' after S2, frequency intensity.
A third heart sound is a normal finding in children, in young adults and during pregnancy.
A third heart sound is usually pathological after the age of 40 years.
The most common causes are left ventricular failure, when it is an early sign, and mitral regurgitation. In heart failure S3 occurs with a tachycardia and S1 and S2 are quiet (lub-da-dub).
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Causes of a third heart sound
Physiological
Healthy young adults
Athletes
Pregnancy
Fever
Pathological
Large, poorly contracting left ventricle
Mitral regurgitation
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Fourth heart sound A fourth heart sound (S4) is less common. It is
soft and low-pitched, best heard with the bell of the stethoscope at the apex. It occurs just before the first sound (da-lub-dub). 0.11'' prior to S1
It is always pathological and is caused by forceful atrial contraction against a non-compliant or stiff ventricle.
A fourth heart sound is most often heard with left ventricular hypertrophy (due to hypertension, aortic stenosis or hypertrophic obstructive cardiomyopathy). It cannot occur when there is atrial fibrillation.
Both a third and a fourth heart sound cause a 'triple' or 'gallop' rhythm.
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Added Sounds
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Pericardial Friction Rub Three Phases
○ Mid Systolic, Mid Diastolic, Pre Systolic
Scratchy, Leathery
Best Heard
○ With Diaphragm of Stethoscope
○ Left Sternal Boarder Leaning over at End Expiration
Apposition of Abnormal Visceral and Parietal Pericardium
Confused with Hamman’s Sign in Post Open Heart Surgery
(Crunch Sound from Mediastinal Air)
It may be audible over any part of the precordium but is often
localized. It is most often heard in acute viral pericarditis and
sometimes 24-72 hours after myocardial infarction. Pericardial rubs
vary in intensity over time, and with the position of the patient.
A pleuro-pericardial rub is a similar sound that occurs in time with the
cardiac cycle but is also influenced by respiration and is pleural in
origin. Occasionally a 'crunching' noise can be heard caused by air in
the pericardium (pneumopericardium). Dr.Vitrag Shah - www.medicalgeek.com
Early Systolic Sounds
Ejection Sound- Usually High Frequency
Aortic Valve- Aortic Stenosis, Bicuspid Aortic
Valve
Pulmonary Valve-Pulmonic Stenosis Vary with
Respirations
Prosthetic Valves- Mechanical, Not
Bioprosthetic
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Mid-Late Systolic Sounds
Click
High Frequency Sound Found in Mitral Valve
Prolapse
Occurs Earlier with Valsalva Maneuver or
Squatting to Standing
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Early Diastolic Sounds
Opening Snap of Mitral Stenosis (MS)
○ High pitched-Left Lateral Decubitus Position, Apex.
0.04-0.12 sec after A2 (S3 occurs 0.12 sec after A2)
○ Occurs after S2, before S3
○ MS More Severe with Short A2-OS Interval & softer
OS or absent OS
Paricardial Knock
○ Chronic Constrictive Pericarditis
○ Mitral Regurgitation
○ Atrial Myxoma
○ Older Model Prosthetic Mitral Valve
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Mechanism of OS
Stenotic anterior mitral valve leaflet suddently bulging download into the left ventricular cavity like a dome, with a snapping sound when the mitral valve is rapidly opened during diastole. So OS is heard only if AML of mitral valve is mobile.
OS occurs when movement of AMV suddenly stops, at point when LVP drops below that of LAP.
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Dr.Vitrag Shah - www.medicalgeek.com
OS S2 S3
Area Just inside
apex/entire
chest wall
2nd & 3rd left ICS Only Apex
Relation to
posture
A2-OS interval
wides on
standing
A2-P2 interval
narrows on
standing
Disappear of
sitting
Intensity on
standing
Remain
same/intensified
Decreases -
Relation to
respiration
A2-OS interval
constant
throught
respiration
Split increase
on respiration
None
Intensity on
respiration
Same - RVS3 Load
during
inspiration
A2-OS/A2-
P2/A2-S3
interval
- A2-P2 interval
shorter than A2-
OS interval
A2-S3 interval is
longer than A2-
OS interval
Pitch High(Best heard
with diaphtagm)
High Low (With Bell)
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Auscultation-
Timing of A2 to OS Interval
Say Timing
seconds
Severity
of MS
Other
HS’s
Prrr 0.06 Severe
Pada .07-.08 Mod-
severe
Pata .08-.09 Mod
Papa 0.10 Mild PK 0.1-0.110
Tu-
huh .12 A2-S3
0.12-0.18
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Gallop:
1)Three or four sounds are spaced to
audibly resemble the center of a horse,
the extra sounds occurs after S2.
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• Protodiastolic gallop rhythm
• S3 gallop, ventricular gallop
rhythm.
• S1 + S2 + pathologic S3
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In early diastole, the blood through
into ventricle from atrium in failing
myocardium, the ventricular wall
tension is poor, produce vibration.
Reflex that the ventricular function
Auscultation character of S3 gallop:
lower in pitch
After S2
Best hear at apex
Loudest at the end of expiration.
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S3 gallop: differ from normal S3
Occur in severe organic heart disease
HR>100 bpm
The interval time between S1 and S2
are almost equal, mimicking quality,
normal S3 is nearer from S2
Normal S3 will disappear in standing
or sitting position
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Late diastolic gallop S4 gallop, atrium gallop
○ At late diastole, related to atrial contraction.
In LVEDP compliance Artial
contraction
occur precede S1, far from S2
low-pitch; best heard at apex
○ Tensity: end of expiration(from LA)
end of inspiration (from RA)
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• Occur in pressure overload,LVH, in
myocardial damaged , LV compliance
, such as BP, IHSS, CHD.
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Summation gallop
Overlapping of S3G and S4G while HR
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Mid Diastolic Sounds
S3
Occurs During Rapid Filling of Left Ventricle (LV) related to LV Volume
Low Frequency Best Heard
○ At the Apex w/Bell
○ Pt in Left Lateral Decubitus Position
Can Be Normal to Age 40???
Can be Pathognomonic for Congestive Heart Failure
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Late Diastolic Sounds
S4
During Atrial Phase of LV Filling
○ Consequence of Ventricular Stiffness
Absent in Atrial Fibrillation or Ventricular
Pacing
Low Frequency Sound Best Heart
○ At the Apex
○ Pt in Left Lateral Decubitus Position
HTN, Aortic Stenosis, Ischemic Heart Disease
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Diastolic Sounds
Right Sided S3, S4
Left Lower Sternal Boarder
Intensity Varies with Respiration due to Right
Heart Filling (Carvallo’s Sign)
Summation Gallop
Occurrence of an Over Lapping S3 and S4 due
to Tachycardia
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Dr.Vitrag Shah - www.medicalgeek.com
Murmurs (Latin word) Sudden deceleration of blood produces
heart sounds while Heart murmurs are produced by turbulent flow (Raynold’snumber >2000) across an abnormal valve, septal defect or outflow obstruction, or by increased volume or velocity of flow through a normal valve.
Murmurs may occur in a healthy heart. These 'innocent' murmurs occur when stroke volume is increased, e.g. during pregnancy, and in athletes with resting bradycardia or children with fever.
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Mechanism
Blood velocity
Blood vascosity
Valve: narrowed or incompetent;
organic or relative
Abnormal connection
Vibration of loose structure
Diameter of vessel or
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Dr.Vitrag Shah - www.medicalgeek.com
Points to be examined in murmur
Timing
Shape
Intensity
Duration
Location of maximum intensity
Character
Pitch
Radiation
Variation with respiration
Variation with position
Variation with other maneuvers
Best heard with bell or diaphram
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Common Murmurs and
Timing
Systolic Murmurs
Aortic stenosis
Mitral insufficiency
Mitral valve prolapse
Tricuspid insufficiency
Diastolic Murmurs
Aortic insufficiency
Mitral stenosis
S1 S2 S1
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Describing a heart murmur
1. Timing
murmurs are longer than heart sounds
HS can distinguished by simultaneous palpation of the
carotid arterial pulse
systolic, diastolic, continuous
2. Shape
crescendo (grows louder), decrescendo, crescendo-
decrescendo, plateau
3. Location of maximum intensity
is determined by the site where the murmur originates
e.g. A, P, T, M listening areas
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Describing a heart murmur con’t:
4. Radiation
reflects the intensity of the murmur and the direction
of blood flow
5. Intensity
graded on a 6 point scale
○ Grade 1 = very faint
○ Grade 2 = quiet but heard immediately
○ Grade 3 = moderately loud
○ Grade 4 = loud
○ Grade 5 = heard with stethoscope partly off the chest
○ Grade 6 = no stethoscope needed
*Note: Thrills are assoc. with murmurs of grades 4 - 6
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Describing a heart murmur con’t:
6. Pitch
high, medium, low depending upto high/medium/low
velosity jet
7. Quality
blowing, harsh, rumbling, and musical
8. Others:
i. Variation with respiration
○ Right sided murmurs change more than left sided
ii. Variation with position of the patient
iii. Variation with special maneuvers
○ Valsalva/Standing => Murmurs decrease in length and intensity
EXCEPT: Hypertrophic cardiomyopathy and Mitral valve prolapse
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Dr.Vitrag Shah - www.medicalgeek.com
Grades of intensity of murmur
Grade 1 Heard by an expert in optimum conditions
Grade 2 Heard by a non-expert in optimum conditions
Grade 3 Easily heard; no thrill
Grade 4 A loud murmur, with a thrill
Grade 5 Very loud, often heard over wide area, with thrill
Grade 6 Extremely loud, heard without stethoscope
Levine & Freeman’s Grading
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Physiological maneuver
1) Change the body position
- Left recumbent: MS
- Sitting, leaning forward: AI
- Squatting from standing, supine position,
raising two legs may increase venous
return, SV CO
- Murmur of MI, AI
- Murmur of IHSS
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2) Respiration
- Deep inspiration: thorax pressure
venous return, pulmonary circulation
clockwise rotation of heart makemurmur
of TI, TS ,PI
- Expiration:
- Valsalva maneuver: thorax pressure
venous return M of IHSS
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3) Exercise:
- HR
- Blood volume
- Blood velocitymake the murmur of MS
Left sided murmurs increases on expiration
while right sided murmur increased on
Inspiration.
Basal (Aortic & Pulmonary) murmurs increases
on sitting and leaning forward while apical (Mitral &
Tricuspid) murmurs increases on left lateral position.
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Systolic Murmurs
Derived from increased turbulence associated
with:
1. Increased flow across normal SL valve or into a
dilated great vessel
2. Flow across an abnormal SL valve or narrowed
ventricular outflow tract - e.g. aortic stenosis
3. Flow across an incompetent AV valve - e.g. mitral
regurg.
4. Flow across the interventricular septum
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Holosystolic vs Pansystolic
murmur
A holosystolic murmur is one which lasts from the end of S1 to the beginning of S2.
A pansystolic murmur is one which lasts from the beginning S1 to the end of S2, and therefore obscures these heart sounds.
The difference between them is academic in terms of the diagnosis. Pansystolicmurmurs are often louder and more significant.
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Diastolic Murmurs
Almost always indicate heart disease
Two basic types:
The term early diastolic murmur is misleading because the murmur usually
lasts throughout diastole, but it is loudest in early diastole.
1. Early decrescendo diastolic murmurs
signify regurgitant flow through an imcompetent semilunar valve
○ e.g. aortic regurgitation
2. Rumbling diastolic murmurs in mid- or late diastole
suggest stenosis of an AV valve
○ e.g. mitral stenosis
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Classification and causes of diastolic murmur
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Continuous Murmurs
Begin in systole, peak near s2, and continue into all or
part of diastole.
1. Cervical venous hum
Audible in kids; can be abolished by compression over the IJV
2. Mammary souffle
Represents augmented arterial flow through engorged breasts
Becomes audible during late 3rd trimester and lactation
3. Patent Ductus Arteriosus
Has a harsh, machinery-like quality
4. Pericardial friction rub
Has scratchy, scraping quality
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Non-Audible murmurs at apex
and pulmonary area
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Functional Murmur: short and soft SEM
Normal S1 and S2
Normal cardiac impulse
No evidence for hemodynamic
abnormality
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Innocent or Normal Murmurs-
Systolic Vibratory Systolic Murmur (Still’s Murmur)
Pulmonic Systolic Murmur (Pulmonary Trunk)* Mammary Soufflé*
Peripheral Pulmonic Systolic Murmur (Pulmonary Branches)
Supraclavicular or Brachiocephalic Systolic Murmur
Aortic Systolic Murmur*common in pregnancy
Still’s Murmur ○ Medium Frequency, Vibratory, Originating from
Leaflets of Pulmonic Valve
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Innocent or Normal Murmurs-
Continuous
Venous Hum
Continuous Mammary Soufflé
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Changing murmurs
Murmurs which change in character or
intensity from moment to moment.
Carey-coombs’ murmur
Infective endocarditis
Atrial Thrombus
Atrial Myxomas
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The Carey Coombs murmur or
Coombs murmur A clinical sign which occurs in patients with
mitral valvulitis due to acute rheumatic fever.
It is described as a short, mid-diastolic rumble best heard at the apex, which disappears as the valvulitis improves.
It is often associated with an S3 gallop rhythm, and can be distinguished from the diastolic murmur of mitral stenosis by the absence of an opening snap before the murmur.
The murmur is caused by increased blood flow across a thickened mitral valve.
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Named murmurs Carey Coombs murmur- Mid diastolic murmur, in
rheumatic fever
Austin Flint murmur- mid- late diastolic murmur,inAortic Regurgitation.
Graham- Steel murmur- high pitched, diastolic, inpulmonary regurgitation.
Rytands murmur - mid diastolic atypical murmur, in Complete heart block.
Docks murmur-diastolic murmur, Left Anterior Descending(LAD) artery stenosis.
Mill wheel murmur- due to air in RV cavity following cardiac catheterization.
Stills murmur- inferior aspect of lower left sternalborder, systolic ejection sound,vibratory/musical quality,in subaortic stenosis, small VSD
Gibson’s murmur: continous machinary murmur of PDA
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Gallaverdin Phenomenon: The Gallavardin phenomenon is a clinical sign found in
patients with aortic stenosis. It is described as the dissociation between the noisy and musical components of the systolic murmur heard in aortic stenosis.
The harsh noisy component is best heard at the upper right sternal border radiating to the neck due to the high velocity jet in the ascending aorta. The musical high frequency component is best heard at the cardiac apex.
The presence of a murmur at the apex can be misinterpreted as mitral regurgitation. It is presumably due to high frequency vibrations traveling to the apex from the calcific aortic valve.
However, the apical murmur of the Gallavardin phenomenon does not radiate to the left axilla and is accentuated by a slowing of the heart rate (such as a compensatory pause after a premature beat) whereas the mitral regurgitation murmur does not change.
The sign is named after Louis Gallavardin, having been described by Gallavardin and Ravault in 1925.
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Dynamic Auscultation
All patients with a new murmur should
undergo dynamic auscultation:
Respiration: right sided murmurs are louder during
inspiration, expiration has the opposite effect
Valsalva manoeuvre:
Postural Changes
Isometric exercise
Squatting:
Vasoactive agents – Amyl Nitrite
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Respiration
Expiration :A2,P2 of second Heart sound separated <30ms ;single sound
Inspiration: Splitting interval widens ;A2,P2 heard as 2 distinct sounds
DIASTOLIC & EJECTION SOUNDS:
S3 & S4 from Rt ventricle;augment in inspiration ;diminish during exhalation.
Opening Snap of MV- soft in inspiration;loud in exhalation
Inspiration decreases intensity of ejection sounds in PS , No effect on aortic ejection sounds.
MURMURS
Inspiration: Diastolic murmur of TS,Pulmonaryregurgitation murmur,systolic murmur of TR,pre-systolic murmur of Ebstein anomaly are accentuated
Mid-systolic click, systolic murmur of MVP accentuated.
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Valsalva Maneuver
Deep inspiration followed by forced exhalation against a closed glottis for 10-20 secs.
Phase 1:transient rise in systemic arterial pressure.
Phase 2:decrease in systemic venous return,systolic pressure & pulse pressure; reflex tachycardia.
Phase 3:abrupt transient decrease in arterial pressure.
Phase 4: overshoot of systemic arterial pressure & reflex bradycardia.
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Phase 2:
S3 & S4 attenuated.
A2-P2 interval narrows
Systolic murmurs of AS & PS;MR,TR diminish.
Diastolic murmurs of AR &PR;TS,MS-soften.
Lt ventricular volume decreases;systolic murmur of HOCM amplifies ;click,late systolic murmur of MVP begins earlier.
Phase 3:
Sudden increase in systemic venous return;wide split of S2;augmentation of murmurs & filling sounds Rtside heart.
Phase 4:
Murmurs & filling sounds Lt side return to control & transiently increase.
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Postural changes & Exercise:
Lying from standing/passive elevation of both legs :
Widening of S2 split
Augmentation of Rt S3 & S4; Lt S3,S4
Systolic murmurs of PS,AS,MR,TR& VSD augmented
Lt ventricular EDV increased;systolicmurmur of HOCM diminished & mid-systolic click,late systolic murmur of MVP are delayed /attenuated.
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Squatting
Increase in venous return & systemic resistance simultaneously;Stroke volume and arterial pressure rise-transient reflex bradycardia.
Augmentation of S3 & S4 (both ventricles)
Systolic murmurs of PS & AS ;diastolic murmurs of TS & MS become louder.(Rt sided preceding Lt)
Elevated arterial pressure;increases blood flow through Rt ventricular outflow tract in TOF
Systolic murmur of VSD increases.
The combtn of increase in arterial pressure and increase in venous return increases Lt ventricular size which decreases obstruction to outflow;intensityof HOCM murmur ;mid-systolic click,late systolic murmur of MVP delayed.
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Left Lateral recumbent position
Accentuates S1,S3,S4 from Lt side of the heart.
OS,murmurs of MS,MR;Mid-systolic click and late systolic murmur of MVP.
Isometric Exercise
Increase in systemic vascular resistance,arterialpressure,HR,CO,Lt ventricular filling pressure and heart size.
S3 & S4 on Lt side is accentuated.
Systolic murmur of AS decreases.(reduced pr gradient across aortic valve.)
Diastolic murmur of AR,systolic murmur of MR ,VSD increase in intensity.
Diastolic murmur of MS –louder.
Systolic murmur of HOCM decreases & systolic click, late systolic murmur of MVP is delayed.(increase in LV volume)
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Amyl Nitrite
Marked vasodilatation;redtn in systemic arterial
pressure;reflex tachycardia;increase in CO and
HR
S1 augmented;A2 diminished
OS of mitral and tricuspid valve become louder
A2/OS interval shortens
S3 augmented
Systolic murmurs of AS,PS,HOCM,TR and
functional systolic murmurs are accentuated.
Dr.Vitrag Shah - www.medicalgeek.com
Murmur Analysis with Dynamic Auscultation
Dr.Vitrag Shah - www.medicalgeek.com
Back to the Basics
1. When does it occur - systole or diastole
2. Where is it loudest - A, P, T, M
I. Systolic Murmurs:
1. Aortic stenosis - ejection type
2. Mitral regurgitation - holosystolic
3. Mitral valve prolapse - late systole
II. Diastolic Murmurs:
1. Aortic regurgitation - early diastole
2. Mitral stenosis - mid to late diastole
Dr.Vitrag Shah - www.medicalgeek.com
Summary
A. Presystolic murmur
Mitral/Tricuspid stenosis
B. Mitral/Tricuspid regurg.
C. Aortic ejection murmur
D. Pulmonic stenosis (spilling
through S20
E. Aortic/Pulm. diastolic
murmur
F. Mitral stenosis w/ Opening
snap
G. Mid-diastolic inflow murmur
H. Continuous murmur of PDADr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
Dr.Vitrag Shah - www.medicalgeek.com
THANK YOU
Dr.Vitrag Shah - www.medicalgeek.com