Murmur of mitral regurgitation

Type of systolic murmur in MR is determined by the chronicity of murmur and its etiology

• Holosystolic murmur – Mitral regurgitation begins during isovolumetric contraction phase and continue till isovolumetric relaxation phase. Heard in rheumatic mitral regurgitation
• Tapering holosystolic murmur occur due to severe mitral regurgitation with a small left atrium occur in acute MR.
• Holosystolic murmur with mid systolic accentuation is heard in severe mitral regurgitation
• Holosystolic murmur with late systolic accentuation occur in MVP and papillary muscle dysfunction
• Late systolic murmur heard in mitral valve prolapse and papillary muscle dysfunction.

Describe the frequency of murmur in MR

Murmur in MR is a high pitched murmur. In severe MR, When the  pressure gradient decreases towards the end of systole low pitched vibrations can occur.

Where will you auscultate for MR murmur?

Classically heard in mitral area

If the anterior leaflet is affected murmur conduct towards axilla

If the posterior mitral leaflet is affected it will be conducted to base of heart.

Murmur may be heard over entire vertebral column if there is large left atrium.

Which is the ideal position, for auscultation  for MR and Why?

Left lateral position is the most suitable position because there is accentuation of halosystolic nature of murmur

Intensity of murmur is increases in this position

What is effect of VPC (Ventricular premature contraction)

Following ventricular premature beat there won’t be any beat to beat variation of murmur.

Following VPV beat to beat variation of murmur occur in aortic stenosis.

What are the causes of decreased intensity of murmur in MR

Murmur may be of decreased intensity in low flow states and associated valve lesion.

Low flow states are Left ventricular dysfunction and Pulmonary artery hypertension

Associated valve lesions that reduce the murmur intensity is Mitral stenosis

Etiology of MR – MR due to following reasons are associated with low intensity of murmur

• MR due to acute myocardial infarction
• MR due to left ventricular dilation 
• MR due to papillary muscle dysfunction

Other causes are 

Obesity

COPD (Chronic obstructive pulmonary disease)

What is Seagull’s murmur

When patient develop infective endocarditis over mitral regurgitation it will alter the character of murmur resulting in musical quality to the murmur. Ruptured chordac act as the string of musical instrument also called as Cooing Dove murmur. Can also occur in acute myocardial infarction and acute rheumatic fever.
Murmur of mitral regurgitation

Typical murmur of mitral regurgitation

• High pitched
• Soft blowing
• Pansystolic murmur
• Best heard with diaphragm of stethoscope
• Patient in left lateral position
• At the height of expectation
• The murmur radiate towards the left axilla and inferior angle of scapula