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Regurgitant Systolic Murmurs
Chapter 15
Are G. Talking, MD, FACC
Patricia L. Thomas, MBA, RCIS
Mitral Regurgitation
Tricuspid Regurgitation
Ventricular Septal Defect
Patent Ductus Arterious
Acute Ventricular Septal Perforation
Papillary Muscle Rupture
Mitral Valve Prolapse Syndrome
• 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,
Chronic Mitral Regurgitation
• Continues as long as LV
pressure > that of the
enlarged LA
• Begins at S1 and extend
through S2
• Large high pitched,
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
– Tricuspid honk or
whoop (highly
• Tricuspid Insufficiency is commonly secondary to
dilatation of the right ventricle
• Severe Right Heart Failure secondary to mitral
• Pulmonary Heart Disease with pulmonary
• Congenital deformity (Epstein's Anomaly),
Rheumatic Valve disease, or Infective
• Listen with the diaphragm of the stethoscope
along the lower left sternal border (third
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
– 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
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp. 180-196