Dr Muhammed Aslam Junior Resident Pulmonary Medicine ACME Pariyaram Presented at Sahakarana Hrudayalaya

1. Diastolic Murmurs
Dr Muhammed Aslam
Junior Resident
Pulmonary Medicine
ACME Pariyaram
Presented at Sahakarana Hrudayalaya

2. Diastolic Murmurs
• Always signify an abnormal cvs structurally or functionally
• Not graded by intensity but by their length
• Thrill additionally mentioned

3. Classification
A) Those arising at the AV valves
1.Mid diastolic
2.Presystolic
3.Combined
B) Those arising at semilunar valves
1.Early diastolic
2.Mid diastolic sounding early diastolic

5. Diastolic murmurs at AV valves

6. Mechanism and Causes of
Diastolic Murmurs at Apex
A- Narrowing of mitral valve or left ventricular inflow
1.Mitral stenosis
2.Left atrial myxoma
3.Cor-triatrium
4.Constriction of AV groove as in constrictive
pericarditis
5.Hypertrophic cardiomyopathy (narrow inflow
cavity

7. Mechanism and Causes of Diastolic
Murmurs at Apex
B.Increased flow across AV valve
1.Left to right shunts (post tricuspid shunts)
(VSD,Ductus,systemic artero venous
fistula,RSOV in to right ventricle,aotopulmonary
window/fistula, Truncus Arteriosus)
2.Mitral Regurgitation (severe)
3.Hyperkinetics circulatory
states(anemia,thyrotoxicosis,pregnancy)
4.Chronic complete heart block

8. Mechanism and Causes of Diastolic
Murmurs at Apex
C. Mechanisms that interfere with mitral valve opening
Austin flint murmur with severe aortic regurgitation
D.Ventricular aneurysm with a narrow neck
E.Murmurs arising some where else but heard at apex
1.Aortic regurgitation
2.Tricuspid stenosis
3. Tricuspid flow murmur of ASD
4.Ebstien’s anomaly

9. Mitral Stenosis murmur features
Features
Description
Site of best audibility
apex
Timing
Mid-diastolic/ pre systolic
Selective conduction
Localised to apex
character
Rough, rumbling (low pitched)
length
Short/moderate/long
respiration
Increases during expiration
posture
>left lateral , < standing
Amyl nitrate inhalation
increases
Isotonic exercise
increases
Isometric hand grip
variable

10. Mechanism of MDM in MS
• As the mitral valve become stenotic the
left atrial pressure increases with a
gradient between left atrium and left
ventricle in diastole. The opening snap
result from abrupt opening of the doming
mitrale valve. As the atrial contraction
contributes to increased gradient in pre
systole, there is pre systolic accentuation
of murmur

11. Mechanism of pre systolic
murmur
• Atrial contraction
• Persistent atrio ventricular gradient
• Left ventricular contraction in presystole
reducing mitral funnel

12. Absence of presystolic murmur in MS
•
•
•
•
•
Atrial fibrillation
Mild MS
Prolonged PR interval
Bradycardia
Elevated LVEDP (left ventricular
dysfunction)

13. Severity of MS : Auscultatory
features
Severity of ms
S2-os interval in
second
features
mild
0.08-0.12
Short mdm/ or pre
systolic murmur or
murmur may appear with
exercise
moderate
0.06-0.08
MDM + pre systolic
murmur with a gap
between them.
Varying degree of MDM
in atrial fibrillation
sever
0.04-0.06
MDM + pre systolic
murmur with no gap.pre
systolic murmur with
atrial fibrillation

14. • With a HR 70-90/min a normal cardiac out
put and a normal left ventricular end
diastolic pressures , the longer murmur the
more severe the stenosis.

15. Mechanism influencing the
length of murmur in MS
1)
2)
3)
4)
5)
Cardiac output
Heart Rate
Left atrial pressure
Left ventricular end diastolic pressure
Heart Rhythm
When alteration in any of the above features occur, the
murmur of Mitral stenosis should not be relied upon to
assess the severity of mitral stenosis

16. Character of murmur
• Rough, rumbling (low pitched)
• Non calcific valve – Very low frequency,
loud diastolic murmur with a thrill
• Severe calcific valve – high frequency,
less intensity , no thrill
• Heard with bell of diaphragm

17. Tricuspid diastolic murmurs
mechanism
causes
Obstruction to rt ventricular inflow
•Tricuspid valve stenosis
A-rheumatic
B-congenital
C-carcinoid
•Right atrial tumorsmyxoma/secondary
•Ebsteins anomaly
Increased flow across valve
Pre tricuspid shunts
A-ASD
B-TAPVC
C-RSOV TO RA
D-LV TO RA communications
E-coronary artery to RA
communication
F-Lutembachers syndrome
G-partial anomalous venous
connection

18. Tricuspid diastolic murmurs
mechanism
causes
Interference with opening of TV
Severe tricuspid regurgitation
A-functional
B-organic
Murmur produced somewhere else
but also heard at tricuspid area
•Severe TR with right sided Austin
Flint murmur
•MS
•Pulmonary regurgitation
•Aortic regurgitation
Murmurs mistaken for tricuspid
diastolic murmur
•Normal pressure pulmonary
incompetence
•Pericardial rub
•Right sided s4 may sound like pre
systolic murmur

19. The murmur of tricuspid stenosis
features
descriptions
Site of best audibility
Tricuspid area
timing
Pre systolic with or without Mid diastolic
length
Short/moderate/long
character
Rough/rumbling
Selective conduction
Localised to tricuspid area
Relation to physiological act
•Respiration
•Posture
•Increased during inspiration
•Increase in supine , passive leg raising
•Rapid deep breathing
•increases

20. • Length of murmur is directly related to the
severity of tricuspid stenosis
• Significant tricuspid stenosis with shorter
or no murmur : causes
1)Rheumatic TS with accompanying MS, severe PAH
,Increased Right ventricular end diastolic pressure
2) Diuretic therapy in TS
3) Atrial fibrillation ( absent pre systolic murmur)
4) Ebstein’s Anomaly of tricuspid valve

21. Other mid diastolic murmurs at
the AV valve
1)
•
•
•
•
•
•
Mid diastolic murmur of MR
Mid diastolic and shorter
Associated with s3
Never pre systolic
Suggest severe MR
Favors rheumatic MR
First sound is usually diminished or absent

22. 2.MDM of L to R shunt
Tricuspid flow murmur in ASD
•
•
•
•
•
Best heard at lower left sternal border but may be
heard at apex or upper left sternal border
Only mid diastolic with no presystolic murmur
Relatively soft or medium frequency
No significant change with respiration
Indicate pulmonary flow to be twice the systemic flow or
higher

23. Causes of Tricuspid flow
murmur
A)Left to right shunts(pre tricuspid)
1.ASD
2.PAVC
3.RSOV
4.Coronary cameral fistula in to rt atrium
5.Left ventricular right atrial communication
(Gerbodes defect)

24. Causes of Tricuspid flow
murmur
B) Admixture lesions ( Cyanotic heart
disease)
1.TAPVC
2.Single atrium
3.Hypoplastic left heart syndrome ( mitral atresia)
C)Severe tricuspid regurgitations
D)The right sided Austin-Flint murmur in
severe functional pulmonary regurgitation

25. Causes of mitral flow murmurs
A) Left to right shunts (post tricuspid shunts)
1.VSD
2.PDA
3.Aorto pulmonary window
4.Systemic arteriovenous fistula

26. Causes of mitral flow murmurs
B) Admixture lesion (cyanotic heart disease)
i) Increased pulmonary flow
1.DORV
2.SINGLE VENTRICLE
3.TRUNCUS ARTERIOSUS
4.TRICUSPID ATRESIA WITH LARGE VSD BUT NO PS
5.EXTENSIVE BRONCHOPULMONARY COLLATERALS IN PULMONARY
ATRESIA OR ANY CYANOTIC HEART DISEASE WITH DIMINISHED
BLOOD FLOW
6.SYSTEMIC TO PULMONARY ARTERY SHUNTS
ii) Diminished pulmonary flow
TRICUSPID ATRESIA WITH PULMONIC STENOSIS

27. Causes of mitral flow murmurs
C. Hyperkinetic circulatory states
1.Severe anemia
2.Thyrotoxicosis
D. Severe mitral regurgitation

28. Austin Flint Murmur
•
•
•
•
In moderate to severe AR
Mid diastolic and/or presystolic
Low pitched best heard with bell
Heavy jet of aortic regurgitation impinging on the
anterior leaflet of mitral valve preventing adequate
opening of the valve and creating turbulence to flow
from left atrium to ventricle in diastole
• with premature closure of mitral valve as in free
severe AR or a/c AR the pre systolic murmur does
not occur.

29. Austin Flint Murmur
• With isometric hand grip, the degree of
aortic regurgitation increases due to
elevated peripheral vascular resistance
and flint murmur increases.
• With administration of vaso dilators , the
murmur decreases or disappear due to
reduction in severity of AR

30. Austin Flint vs MS
Features
Austin Flint
MS
1.Diastolic Thrill
Rare
Common
2.Amyl Nitrate Inhalation
↓
↑
Isometric hand grip /
vasopressors
↑
variable
s1
↓/N
↑
OS
-
+
LV s3
May occurs
never
Rhythm
Sinus rhythm
AF is common

31. Auscultatory phenomena
simulating mid- diastolic murmurs
1.
2.
3.
4.
S3 as MDM
S4 as presystolic murmur
S3+s4 together as MDM
Pericardial knock of constrictive
pericarditis
5. Pericardial rub
6. The early diastolic murmur of AR at apex

32. Other Mid Diastolic Murmur
• Carey Coomb’s murmurs
– Acute rheumatic fever, mitral valve structures acutely inflamed with
some thickening and edema turbulence of flow during the rapid filling
phase + moderate MR [increased mitral inflow in diastole]
– Low pitched short MDM.
– Distinguished from MS MDM by the absence of opening snap before
the murmur
– good evidence of active carditis

33. Early diastolic murmur

34. AR murmur
• Timing - Early diastolic
• Site of best audibility – best heard along left sternal
border, but is also well heard at right 2nd space and
apex.
Left sternal border murmur of AR
causes
Right sternal border murmur of AR
causes
1.
2.
3.
4.
1.
2.
3.
4.
5.
Rheumatic heart disease
Congenital bicuspid valve
IE
AR in association with valvular
AS or subvalvular fixed AS
5. Prosthetic AR
Syphilis
Marfan syndrome
Ankylosing spondylitis
Rheumatoid arthritis
AR associated with TOF or VSD

35. AR murmur
• Character- high frequency / soft / blowing/
musical
• Thrill is rare
• Length of the murmur correlates with
severity

36. AR murmur
Causes of AR with short or no murmur
1. a/c AR
2. LVF
3. Tachycardia
4. Hypotension
5. Vasodilators
6. Pregnancy

37. Relation to physiological act
• Respiration and posture – best heard in
sitting ( or standing ) leaning forward , held
in expiration
• Isometric hand grip - ↑
• Vasopressor - ↑
• Vasodilator - ↓
• Squatting - ↑

38. maneuver
mechanisms
Sitting,leaning forward,held
expiration,diaphragm firmly
applied to chest
•Aorta nearer to chest
•Non interference with the noise
of breathing
•Improved quality of diaphragm
to appreciate the high frequency
murmur
Prone position
Aorta nearer to chest
Prompt squatting
Increased systemic vascular
resistance
Isometric hand grip
As above
vasopressors
•Increased systemic resistance

39. Auscultatory events or murmurs simulating AR
Auscultatory event /murmur
Differentiating feature
PR with PAH (Graham Steel murmur)
•Not audible at Rt side of sternum and
apex
•May ↑ with inspiration
•↓ with standing / inspiration
MDM of severe MS at apex and
occasionally along LSB
Low frequency , better heard with bell
MDM of severe MR when heard along
left sternal border
As above
MDM of TS
•↓ with sitting , standing , during
expiration
•↑ with inspiration , supine position
•Better heard with bell
•Prominent a wave with elevated JVP
Pericardial friction rub when high
frequency or musical
•Changes with posture / respiration
•Never heard to rt of sternum

40. Cole- Cecil murmur
• AR murmur in left axilla due to higher position of apex

41. Murmur of Pulmonary Regurgitation with PAH
(Graham – Steell murmur)
• Timing – early diastolic
• Length- very short to pan diastolic
Length of murmur reflects the duration of
pressure difference between pulmonary
artery and right ventricle in diastole

42. • Site of best audibility – pulmonary area
• Character – high pitched (PR with no PAH
is low frequency )
• Conduction – left sternal border 3 rd and 4
th spaces

43. Relation to physiological act
• Respiration – may incrs during inspirationmainly in PR with no PAH
• Posture – better heard in supine posture
,passive leg raising
• No influence for isometric hand grip/
vasopressors/amyl nitrite inhalation

44. PR with normal pressure
Feature
Description
Timing
Mid - diastolic
length
Short , never pan diastolic
Site of best audibility
Pulmonary area
character
Low frequency , rumbling
conduction
Localised to pulmonary area , may be
heard along left sternal border
Relation to physiological act
1. Posture
•
2. Respiration
•
Incrs during supine / passive leg
raising .Decrs with standing
Incrs with inspiration.Decrs with
exprn

45. Other diastolic murmurs
• Cabot– Locke Murmur- [Diastolic Flow murmur]
- in severe anemia
– The Cabot–Locke murmur is a diastolic murmur that sounds similar to
aortic insufficiency but does not have a decrescendo; it is heard best at
the left sternal border. [High flow thru coronary vessels, LMCA, LAD]
– The murmur resolves with treatment of anaemia.
• Dock’s murmur
– diastolic crescendo-decrescendo, with late accentuation, [consistent
with blood flow through the coronary] in a sharply localized area, 4 cm
left of the sternum in the 3LICS, detectable only when the patient was
sitting upright.
– Due to stenosis of LAD

46. Other diastolic murmurs
• Key–Hodgkin murmur
– EDM of AR; it has a raspy quality, [sound of a saw cutting through
wood]. Hodgkin correlated the murmur with retroversion of the aortic
valve leaflets in syphilitic disease.
• Rytand’s murmur
– Late diastolic murmur in complete heart block

47. THANK YOU !!!