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Diastolic Murmurs

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

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

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

Diastolic murmurs at AV valves

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

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

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.Ebstiens anomaly

Mitral Stenosis murmur features

Features Site of best audibility Timing Selective conduction character length respiration posture Amyl nitrate inhalation Description apex Mid-diastolic/ pre systolic Localised to apex Rough, rumbling (low pitched) Short/moderate/long Increases during expiration >left lateral , < standing increases

Isotonic exercise Isometric hand grip

increases variable

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

Mechanism of pre systolic murmur

Atrial contraction Persistent atrio ventricular gradient Left ventricular contraction in presystole reducing mitral funnel

Absence of presystolic murmur in MS

Atrial fibrillation Mild MS Prolonged PR interval Bradycardia Elevated LVEDP (left ventricular dysfunction)

Severity of MS : Auscultatory features

Severity of ms mild S2-os interval in second 0.08-0.12 features Short mdm/ or pre systolic murmur or murmur may appear with exercise



MDM + pre systolic murmur with a gap between them. Varying degree of MDM in atrial fibrillation
MDM + pre systolic murmur with no gap.pre systolic murmur with atrial fibrillation



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.

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

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

Tricuspid diastolic murmurs

mechanism Obstruction to rt ventricular inflow causes Tricuspid valve stenosis A-rheumatic B-congenital C-carcinoid Right atrial tumorsmyxoma/secondary Ebsteins anomaly 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

Increased flow across valve

Tricuspid diastolic murmurs

mechanism Interference with opening of TV causes Severe tricuspid regurgitation A-functional B-organic Severe TR with right sided Austin Flint murmur MS Pulmonary regurgitation Aortic regurgitation Normal pressure pulmonary incompetence Pericardial rub Right sided s4 may sound like pre systolic murmur

Murmur produced somewhere else but also heard at tricuspid area

Murmurs mistaken for tricuspid diastolic murmur

The murmur of tricuspid stenosis

features Site of best audibility timing descriptions Tricuspid area Pre systolic with or without Mid diastolic



Selective conduction Relation to physiological act Respiration Posture Rapid deep breathing

Localised to tricuspid area

Increased during inspiration Increase in supine , passive leg raising increases

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) Ebsteins Anomaly of tricuspid valve

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

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

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)

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

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

Causes of mitral flow murmurs

B) Admixture lesion (cyanotic heart disease) i) Increased pulmonary flow

ii) Diminished pulmonary flow


Causes of mitral flow murmurs

C. Hyperkinetic circulatory states 1.Severe anemia 2.Thyrotoxicosis D. Severe mitral regurgitation

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.

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

Austin Flint vs MS
Features Austin Flint MS

1.Diastolic Thrill
2.Amyl Nitrate Inhalation



Isometric hand grip / vasopressors s1 OS LV s3 Rhythm


/N May occurs Sinus rhythm

+ never AF is common

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

Other Mid Diastolic Murmur

Carey Coombs 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

Early diastolic murmur

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.

Rheumatic heart disease Congenital bicuspid valve IE AR in association with valvular AS or subvalvular fixed AS 5. Prosthetic AR

1. 2. 3. 4. 5.

Syphilis Marfan syndrome Ankylosing spondylitis Rheumatoid arthritis AR associated with TOF or VSD

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

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

Relation to physiological act

Respiration and posture best heard in sitting ( or standing ) leaning forward , held in expiration Isometric hand grip - Vasopressor - Vasodilator - Squatting -

maneuver Sitting,leaning forward,held expiration,diaphragm firmly applied to chest

mechanisms Aorta nearer to chest Non interference with the noise of breathing Improved quality of diaphragm to appreciate the high frequency murmur

Prone position Prompt squatting

Aorta nearer to chest Increased systemic vascular resistance

As above Increased systemic resistance

Isometric hand grip vasopressors

Auscultatory events or murmurs simulating AR

Auscultatory event /murmur PR with PAH (Graham Steel murmur) Differentiating feature Not audible at Rt side of sternum and apex May with inspiration with standing / inspiration Low frequency , better heard with bell As above with sitting , standing , during expiration with inspiration , supine position Better heard with bell Prominent a wave with elevated JVP Changes with posture / respiration Never heard to rt of sternum

MDM of severe MS at apex and occasionally along LSB MDM of severe MR when heard along left sternal border MDM of TS

Pericardial friction rub when high frequency or musical

Cole- Cecil murmur

AR murmur in left axilla due to higher position of apex

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

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

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

PR with normal pressure

Feature Description Timing Mid - diastolic


Short , never pan diastolic

Site of best audibility

Pulmonary area


Low frequency , rumbling


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

Other diastolic murmurs

Cabot Locke Murmur- [Diastolic Flow murmur]
- in severe anemia The CabotLocke 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.

Docks 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

Other diastolic murmurs

KeyHodgkin 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.

Rytands murmur
Late diastolic murmur in complete heart block