Category Archives: Cardiology

ejection systolic murmur

Systolic ejection or midsystolic murmurs are due to turbulent forward flow across the right and left ventricular outflow tract, aortic or pulmonary valve, or through the aorta or pulmonary artery.

Turbulence is produced by obstruction to blood flow, vascular dilation, increase in the velocity of flow or a combination.
The ejection of blood begins after closure of the AV or atrioventricular (mitral and tricuspid) valves and is preceded by the time it takes for the ventricular pressures to sufficiently exceed the aortic and pulmonary diastolic pressure and force open the aortic and pulmonary valves. Because of this delay, there is a silent interval between the first heart sound (S1 is produced by closure of the AV valves) and onset of the murmur.
Since ejection ends before closure of the outflow or semilunar (aortic or pulmonary) valve, there is another silent interval between the end of the murmur and closure of the valve on the side from which it originates. Thus, left sided murmurs will terminate before closure of the aortic valve (A2 component of S2) while right-sided murmurs will end before closure of the pulmonary valve (P2 component of S2).

In contrast, the holosystolic murmur of mitral regurgitation (MR) begins with S1 and continues throughout systole and up to S2, without intervening silent intervals. Use the “play” buttons on the above animation to toggle between an ejection and a holosystolic murmur.

The ejection murmur first increases and then decreases in intensity (known as a cresecendo-decrescendo pattern) to give it a “diamond shaped” configuration. The overall intensity of the murmur is proportional to the rate of ventricular ejection. Also, the intensity of the murmur at any given point of ejection is dependent upon flow at that specific time. Thus, if flow is highest in early ejection, the intensity of the murmur will peak early. In contrast, the murmur will peak late if flow is higher during the later phase of ejection.

Pansystolic murmur of Mitral Regurgitation

Pansystolic or Holosystolic murmurs begin at the very onset of systole, as pressure in the ventricle exceeds that in the atrium. Hence, the murmur begins with the first heart sound (S1) and continues throughout systole until the diminishing ventricular pressure equals that in the atrium. The murmur goes into and obscures the second sound (S2). The murmur is usually “flat” in intensity and blowing in pitch or timbre.

When regurgitation is of a large magnitude, diastolic blood return from the atrium to the ventricle produces a third heart sound (S3) and a diastolic flow rumble (FR).



Important Heart Murmurs

Austin Flint murmur : Austin Flint murmur is a mid-diastolic rumbling audible in subjects with severe aortic regurgitation that is best heard at the apex with little radiation. Several theories have been suggested for the origin of the murmur: (1) vibration of the anterior mitral valve leaflet due to the regurgitant jet, (2) collision of the jet with mitral inflow, (3) increased mitral inflow velocity due to narrowing of the valve orifice by the jet, and (4) vibration from the jet impinging on the myocardial wall. It differs from mitral stenosis murmur in that ,it occurs in the presence of a murmur of aortic valve insufficiency and in the absence of the rheumatic, mitral opening snap.

Carey Coombs murmur : Mitral valvulitis associated with acute rheumatic fever may cause a low-pitched mid-diastolic rumble. It can be differentiated from the diastolic murmur of Mitral stenosis by the absence of (1)an opening snap, (2)presystolic accentuation & (3)loud first heart sound.

Cruveilhier-Baumgarten murmur : Venous hum heard in epigastric region (on examination by stethoscope) due to collateral connections between portal system and the remnant of the umbilical vein in portal hypertension.

Duroziez’s murmur : Its a to & fro murmur heard over the femoral artery during both systole& diastole. It is elicited by applying gradual arterial compression with the diaphragm of the steth. This compression not only produces systolic murmur(which is the normal result of arterial compression) but also a diastolic murmur(which is pathologic &suggestive of aortic regurgitation).Sensitivity of 58-100%.False positives occur in high output states. In high output states the double murmur is due to forward flow. In Ar one murmur is due to forward flow& the other due to reverse flow.The two can be differnetiated by applying pressure first on the more cephalad edge of the diaphragm & then on its more caudal edge. The murmur of forward flow is enhanced by compressing the cephalad edge. Conversely the reverese flow murmur is enhanced by compressing the caudad edge.

Gibson murmur :The typical continuous “machinery-like” murmur of patent ductus arteriosus.train in tunnel murmur

Graham Steell’s murmur : Due to pulmonary regurgitation in patients with pulmonary hypertension and mitral stenosis. It is a high pitched early diastolic murmur heard best at the left sternal edge in the second intercostal space with the patient in full inspiration.

The murmur is heard due to a high velocity regurgitant flow across the pulmonary valve; this is usually a consequence of pulmonary hypertension. The Graham Steell murmur is often heard in patients with chronic cor pulmonale as a result of chronic obstructive pulmonary disease.

Means-Lerman “scratch” murmur: Increased flow across the pulmonary valve in Thyrotoxicosis may be associated with ejection systolic murmur.The ejection systolic murmur owing to hyperthyroidism may have a scratchy quality (Means-Lerman scratch), and, frequently, the intensity of P2 is increased because of mild to moderate pulmonary hypertension.

Roger’s Murmur:A loud pansystolic murmur caused by interventricular septal defect of the heart; maximal at the left sternal border.

Seagull murmur  a raucous murmur with musical qualities, such as that heard occasionally in aortic insufficiency.A “seagull’s cry murmur” is defined as a murmur imitating the cooing sound of a seagull. This type of murmur is typically characterized by a musical timbre and a high frequency, and may occur as a result of various valve diseases. It is usually described as a sign of tight calcific aortic stenosis, when the murmur’s high frequency components are transmitted to the lower left sternal border and the cardiac apex during most of systole (Gallavardin’s phenomenon). In this condition, the typical harsh timbre of the ejective murmur tends to assume a musical high pitched quality, resembling that of mitral regurgitation, which may be reminiscent of the cry of a seagull. A protodiastolic murmur with similar characteristics, typically in decrescendo, may occur in severe aortic valve regurgitation, particularly when the regurgitant flow presents high velocities. However, a seagull’s cry murmur may also be the sign of mitral regurgitation or prolapse. Similarly, the musical and holosystolic sound reflects the presence of high frequency components due to high velocities of reflow.
Still’s murmur An innocent musical murmur resembling the noise produced by a twanging string; almost exclusively in young children, of uncertain origin and ultimately disappearing.{There are five innocent murmurs of infancy and childhood: (i) pulmonary flow murmur, (ii) Still’s murmur, (iii) venous hum, (iv) carotid bruit, (v) physiologic pulmonary branch stenosis murmur of neonate}