Rav Murmurs

Front 1

early diastolic

Back 1

aort regurg
The murmur is low intensity, high-pitched, best heard over the left sternal border or over the right second intercostal space, especially if the patient leans forward and holds breath in full expiration. The radiation is typically toward the apex. The configuration is usually decrescendo and has a blowing character. The presence of this murmur is a good positive predictor for AR and the absence of this murmur strongly suggests the absence of AR. An Austin Flint murmur is usually associated with significant aortic regurgitation.
Pulmonary regurgitation Pulmonary regurgitation is most commonly due to pulmonary hypertension (Graham-Steell murmur). It is a high-pitched and blowing murmur with a decrescendo configuration. It may increase in intensity during inspiration and best heard over left second and third intercostal spaces. The murmur usually does not extend to S1.
Left anterior descending artery stenosis This murmur, also known as Dock's murmur, is similar to that of aortic regurgitation and is heard at the left second or third intercostal space. A Coronary artery bypass surgery can eliminate the murmur

Front 2

mid diast

Back 2

Mitral stenosis This murmur has a rumbling character and is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. It usually starts with an opening snap. In general, the longer the duration, the more severe the mitral stenosis. However, this rule can be misleading in situations where the stenosis is so severe that the flow becomes reduced, or during high-output situations such as pregnancy where a less severe stenosis may still produce a strong murmur. In mitral stenosis, tapping apical impulse is present.
Mid-diastolic Tricuspid stenosis Best heard over the left sternal border with rumbling character and tricuspid opening snap with wide splitting S1. May increase in intensity with inspiration (Carvallo's sign). Tricuspid stenosis often occurs in association with mitral stenosis. Isolated TS are often associated with carcinoid disease and right atrial myxoma.
Mid-diastolic Atrial myxoma Atrial myxomas are benign tumors of the heart. Left myxomas are far more common than right myxomas and those may cause obstruction of the mitral valve producing a mid-diastolic murmur similar to that of mitral stenosis. An echocardiographic evaluation is necessary.
Mid-diastolic Increased flow across the atrioventricular valve This can also produce a mid-diastolic murmur, such as in severe mitral regurgitation where a large regurgitant volume in the left atrium can lead to "functional mitral stenosis."
Mid-diastolic Austin Flint murmur An apical diastolic rumbling murmur in patients with pure aortic regurgitation. This can be mistaken with the murmur in mitral stenosis and should be noted by the fact that an Austin Flint murmur does not have an opening snap that is found in mitral stenosis.
Mid-diastolic Carey-Coombs murmur A mid-diastolic murmur over the left ventricular impulse due to mitral valvulitis from acute rheumatic fever

Front 3

late diast

Back 3

Complete heart block A short late diastolic murmur can occasionally be heard (Rytand's murmur

Front 4

Mid-systolic ejection

Back 4

aortic valve stenosis or hypertrophic cardiomyopathy (HCM), with a harsh and rough quality.
Pulmonic outflow obstruction
Dilation of aortic root or pulmonary artery
Increased semilunar blood flow
IncIreased semilunar blood flow
nnocent midsystolic murmurs

Front 5

late systolic

Back 5

Late systolic Mitral valve prolapse This is the most common cause of late systolic murmurs.
Late systolic Tricuspid valve prolapse Uncommon without concomitant mitral valve prolapse. Best heard over left lower sternal border.
Late systolic Papillary muscle dysfunction Usually due to acute myocardial infarction or ischemia, which causes mild mitral regurgitation.

Front 6

Holosystolic (pansystolic)

Back 6

Tricuspid insufficiency
Mitral regurgitation
Ventricular septal defect

Front 7

Holosystolic (pansystolic) Tricuspid insufficiency

Back 7

Intensifies upon inspiration. Can be best heard over the fourth left sternal border. The intensity can be accentuated following inspiration (Carvallo's sign) due to increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein's anomaly, carcinoid disease, or prior right ventricular infarction.

Front 8

Holosystolic (pansystolic) Mitral regurgitation

Back 8

No intensification upon inspiration. In the presence of incompetent mitral valve, the pressure in the L ventricle becomes greater than that in the L atrium at the onset of isovolumic contraction, which corresponds to the closing of the mitral valve (S1). This explains why the murmur in MR starts at the same time as S1. This difference in pressure extends throughout systole and can even continue after the aortic valve has closed, explaining how it can sometimes drown the sound of S2. The murmur in MR is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary MR. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe MR.

Front 9

Holosystolic (pansystolic) Ventricular septal defect

Back 9

No intensification upon inspiration. VSD is a defect in the ventricular wall, producing a shunt between the left and right ventricles. Since the L ventricle has a higher pressure than the R ventricle, flow during systole occurs from the L to R ventricle, producing the holosystolic murmur. It can be best heard over the left third and fourth intercostal spaces and along the sternal border. It is associated with normal pulmonary artery pressure and thus S2 is normal. This fact can be used to distinguish from pulmonary stenosis, which has a wide splitting S2. When the shunt becomes reversed ("Eisenmenger syndrome"), the murmur may be absent and S2 can become markedly accentuated and single.

Front 10

Late systolic Mitral valve prolapse

Back 10

This is the most common cause of late systolic murmurs. It can be heard best over the apex of the heart, usually preceded by clicks. The most common cause of mitral valve prolapse is "floppy" valve (Barlow's) syndrome. If the prolapse becomes severe enough, mitral regurgitation may occur. Any maneuver that decreases left ventricular volume — such as standing, sitting, Valsalva maneuver, and amyl nitrate inhalation — can produce earlier onset of clicks, longer murmur duration, and decreased murmur intensity. Any maneuver that increases left ventricular volume — such as squatting, elevation of legs, hand grip, and phenylephrine — can delay the onset of clicks, shorten murmur duration, and increase murmur intensity

Front 11

Mid-systolic ejection Aortic valve sclerosis

Back 11

This is due to degenerative thickening of the roots of the aortic cusps but produces no obstruction and no hemodynamic instability and thus should be differentiated from aortic stenosis. It is heard over right second intercostal space with a normal carotid pulse and normal S2.

Front 12

Mid-systolic ejection murmurs are due to

Back 12

blood flow through the semilunar valves. They occur at the start of blood ejection — which starts after S1 — and ends with the cessation of the blood flow — which is before S2. Therefore, the onset of a midsystolic ejection murmur is separated from S1 by the isovolumic contraction phase; the cessation of the murmur and the S2 interval is the aortic or pulmonary hangout time. The resultant configuration of this murmur is a crescendo-decrescendo murmur. Causes of midsystolic ejection murmurs include outflow obstruction, increased flow through normal semilunar valves, dilation of aortic root or pulmonary trunk, or structural changes in the semilunar valves without obstruction.

Front 13

Late systolic murmurs starts after

Back 13

S1 and, if left sided, extends up to S2, usually in a crescendo manner. Causes include mitral valve prolapse, tricuspid valve prolapse and papillary muscle dysfunction.

Front 14

Holosystolic (pansystolic) murmurs start

Back 14

at S1 and extends up to S2. They are usually due to regurgitation in cases such as mitral regurgitation, tricuspid regurgitation, or ventricular septal defect (VSD).[4

Front 15

Early diastolic murmurs start at the same time as

Back 15

S2 with the close of the semilunar valves and typically ends before S1. Common causes include aortic or pulmonary regurgitation and left anterior descending artery stenosis.

Front 16

Mid-diastolic murmurs start after S2

Back 16

and end before S1. They are due to turbulent flow across the atrioventricular valves during the rapid filling phase from mitral or tricuspid stenosis

Front 17

Late diastolic (presystolic) murmurs start

Back 17

after S2 and extends up to S1 and have a crescendo configuration. They can be associated with AV valve narrowing.[4] They include mitral stenosis, tricupsid stenosis, myxoma, and complete heart block.