Download Systolic Ejection Murmurs Chapter 14

Systolic Ejection Murmurs
Chapter 14
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS
Outline
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Outflow Tracts
Inflow Tracts
Inter-Ventricular Flow
Ejection Murmur
Classification of
Ejection
• Aortic Stenosis
• Bicuspid Aortic Valve
• 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 S2
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 S2
• Loudest in the 2nd & 3rd 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
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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
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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