Regurgitant Systolic Murmurs Chapter 15

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Regurgitant Systolic MurmursChapter 15

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

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Outline

• Mitral Regurgitation
• Tricuspid Regurgitation
• Ventricular Septal Defect
• Patent Ductus Arterious
• Acute Ventricular Septal Perforation
• Papillary Muscle Rupture
• Mitral Valve Prolapse Syndrome

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Introduction

• 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, VSDs

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Chronic Mitral Regurgitation

• Continues as long as LV pressure gt that of the
  enlarged LA
• Begins at S1 and extend through S2
• Large high pitched, blowing holosystolic/pansystol
  ic murmur

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Acute Mitral Regurgitation

• Loud Grade IV or gt, diamond shaped
• Pressure in the normal nondilated LA increases
  rapidly because of regurgitant flow in early
  systole and LV pressure in late systole

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Mitral Regurgitation Causes

• Rheumatic Heart Disease
• Papillary Muscle Dysfunction
• Mitral Valve Prolapse
• Rupture Chordae Tendineae
• Calcified mitral Annulus
• LV Dilatation

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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

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• 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
  absent
• Tricuspid honk or whoop (highly musical)

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Causes

• Tricuspid Insufficiency is commonly secondary to
  dilatation of the right ventricle
• Severe Right Heart Failure secondary to mitral
  stenosis
• Pulmonary Heart Disease with pulmonary
  hypertension
• Congenital deformity (Epstein's Anomaly),
  Rheumatic Valve disease, or Infective
  Endocarditis
• Listen with the diaphragm of the stethoscope
  along the lower left sternal border (third
  interspace)

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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

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• 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

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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 lt ½ of patients marks onset of the murmur
  click murmur syndrome
• Cause
• Mitral insufficiency

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THE ENDOFCHAPTER 15

• Tilkian, Ara MD Understanding Heart Sounds and
  Murmurs,
• Fourth Edition, W.B. Sunders Company. 2002, pp.
  180-196