Systolic Ejection Murmurs Chapter 14

Are G. Talking, MD, FACC Instructor Patricia L. Thomas, MBA, RCIS

• Outflow Tracts • Inflow Tracts • Inter-Ventricular Flow • Ejection Murmur • Classification of Ejection • Aortic Stenosis • Bicuspid Aortic Valve

Outline

• Tetralogy of Fallot • Dilatation of the Proximal Pulmonary • Pulmonary Arterial Narrowing • Coarctation of the Aorta • Musical Murmurs

Introduction

• Levine stated, “Systolic noise with a duration longer than a heart sound.” • Result of turbulent blood flow across outflow tracts, ejection murmurs,inflow tract, and from ventricle to ventricle

Outflow Tracts/ Ejection Pathways

• Left outflow tract – Left ventricle – Aortic valve – Aortic root – Ascending Aorta • Right outflow tract – Right ventricle – Pulmonary Valve – Main Pulmonary Artery

Causes of Abnormalities of Flow

• Forward flow across normal outflow tracts • Forward flow across stenosed aortic or pulmonic outflow tracts • High flow across normal right or left ventricular outflow tracts • High flow across a regurgitant aortic or pulmonic valve without significant stenosis • Forward flow into a dilated great vessel

Inflow Tracts

• The inflow tracts of the heart are the chambers that are open to tack other during diastolic filling. – Mitral valve is part of the left inflow tract – Tricuspid valve is part of the right inflow tract • Abnormalities are insufficiency/regurgitant related: rheumatic valvular disease, mitral valve prolapse, or papillary muscle dysfunction

Inter-Ventricular Flow

• Small VSD results in turbulent blood flow from ventricular to ventricle

Ejection Murmur

• Mixed frequencies and is moderate-to-marked crescendo-decrescendo • Caused by forward flow across the left or right outflow • Aortic stenosis & pulmonic stenosis

Classification of Ejection Murmurs

• Early Systolic Ejection Murmur – Commonly heard in a small VSD without pulmonary hypertension, large VSD with pulmonary hypertension, septal perforation resulting from MI, acute severe mitral regurgitation • Mid-systolic Ejection Murmur – Long and is loudest in mid-systolic with the sound of S 2 clearly audible & implies significant aortic or pulmonic outflow tract obstruction, TOF, dilatation of he proximal pulmonary artery or ASD

Aortic Stenosis

• Murmur is harsh, rough, & grunting • Degrees of Obstruction – Mild- softer, shorter & earlier-peaking systolic murmur – Severe-louder, longer, & late-peaking murmur • Causes – Result of congenital aortic valve disease, rheumatic fever (aortic & mitral valve involved), or degenerative calcification in elderly patients • Listen with the diaphragm of the stethoscope for maximal intensity at the second right intercostal space; listen at the apex & over the precordium, both clavicles, both carotids, & suprasternal notch

Pulmonic Valve Stenosis

• Harsh systolic murmur,wide splitting of S 2 • Loudest in the 2 nd & 3 rd interspaces along the left sternal border (pulmonic area) • Palpable Thrill felt directed toward the left neck or clavicle • Murmur peaks in mid-systole with maximal ejection & produces a diamond shape on the phono.

• Heard during expiration • Ejection sound heard over the pulmonary area • Sound caused by doming & abrupt arrest in motion of the stenotic PV

Tetralogy of Fallot

• Described by Fallot in 1888 • VSD, Pulmonic Stenosis, Dextroposition of the aorta & RV hypertrophy • PS results of a fibromuscular ring below the PV in the RV out flow tract-infundibular • More severe the obstruction, the more blood is shunted RT to LT the VSD • Systolic thrill pulmonic with grade IV murmur

Coarctation of the Aorta

• Grade II or III murmur • Heard posteriorly & over base of the heart • Hypertension in the arms, but not in the legs • Decreased or absent femoral arterial pulsation

Musical Murmurs

• Caused by vibrating structure enve in the the absence of flow turbulence • Musical systolic murmurs – Cooing of a dove – Buzzing of a saw – Spinning of a top – Whistling – Systolic whoop – Precordial honk • Mitral valve prolapse can assume such a noise

THE END OF CHAPTER 14

Tilkian, Ara MD Understanding Heart Sounds and Murmurs, Fourth Edition, W.B. Sunders Company. 2002, pp. 154-178