Vascular ejection click

High pitched sound produced by the sudden tensing of the proximal aorta or pulmonary artery during early ejection.It  implies a dilated/hypertensive great vessel that conduct the normal opening sound to the surface.

Decreased vascular compliance is the rule.

Pulmonary ejection click is noticed in

• Dilated pulmonary artery in PAH
• Idiopathic dilatation of Pulmonary artery

Vascular PEC may not soften with inspiration

Aortic ejection click is seen in 

• Aneurysm of aortic root
• Systemic hypertension.
• Aortic root dilatation

AEC of vascular type herad best over aortic area.

Valvular ejection click

It is a high pitched sound produced by the snapping open of the stenotic thickened semilunar valve.
Characteristics of ejection clicks
High pitched sounds
0.05 sec after s.
Valvular clicks are later and more audible
Pulmonary ejection click 
It is heard in Pulmonary stenosis
This is an inconstant EC better during expiration, inspiratory diastolic opening of pulmonary valve in Pulmonarystenosis, thus in inspiration no ejection click is produced
Best heard at the 2-3 LICS. Inaudible at the apex.
Special features of PEC

• Softens with inspiration
• PEC becomes earlier in more severe stenosis
• PECnot usual in ASD unless associated with PAH

What is the mechanism of respiratory variation of PEC?
During inspiration the RV end diastolic pressure comes more than pulmonary artery diastolic pressure hence producing an upward movement of the valve prior to ejection of blood. Thus the partially open valve undergoes less excursion producing a soft sound.

• Always check for the inspiratory variation of PEC
• Always check for PEC with the patient standing up when it becomes more prominent.

Aortic ejection click
It is the valvular aortic stenosis - it is constant both during inspiration and expiration,and is  better heard over the apex and aortic area
AEC of vascular type best over aortic area.
Difference between Aortic and Pulmonary Ejection Clicks
features                Aortic election                           Pulmonic ejection
Site                        Aortic area                                  Pulmonary area
Conduction           Heard all over precordium         Localized to pulmonary area
Accentuation        No change with                           Intensity increase withexpiration
with respiration    respiration

Non-ejection click

This is a mid systolic click in Mitral / Tricuspid valve prolapse followed by late systolic
murmur. NEC is produced by the stretch on the chordae and papillary muscles by the prolapsed cusp of the mitral/tricuspid valve.
Multiple sounds are heard in Ebstein's anomaly - split S„ split S2, OS and S4
Mid Systolic Clicks
Clicks in midsystole are heard in

• Mitral valve prolapse syndrome
• Tricuspid valve prolapse syndrome
• Aneurysm of interatrial or interventricular septum
• Ebstein's anomaly
• Severe aortic regurgitation.

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

Heartsounds in mitral regurgitation

What are the causes of soft S1 in mitral regurgitation

• It is due to the incomplete opposition of valve cusps
• There is partial closure of mitral valve orifice at the onset of ventricular systoli

Causes of loud S1 in MR

• Co-existing mitral stenosis
• MVP – MR
• MR due to papillary muscle dysfunction

What are the causes of left ventricular S3 in MR

• It is due to elevated left ventricular end diastolic volume (LVEDV)
• Due to left ventricular dysfunction – LV dysfunction 

Differential diagnosis of murmur based on site of auscultation

Mitral area : 

Causes of systolic mumur

          MR (Mital regurgitation)

          AS (Aortic stenosis)

Diastolic murmur

          MS (Mitral stenosis)

          AR (Aortic regurgitation)

Tricuspid area:

Systolic murmur

          VSD    (Atrial septal defect)

          PS (pulmonary stenosis)

          TOF (Tetralogy of fallet)

Diastolic murmur

          AR

          PR

Continuous murmur

           PDA (Patent ductuts artenosis)

Aortic area :

Systolic murmur

           AS (Aortic Stenosis)

Posterior thorax : Mitral regurgitation

Thoracic spine :  Coarctation of aorta

Continuous murmur and it’s differential diagnosis

Continuous murmurs are defined as "murmurs that begins in systole and extend through the second heart sound into part or whole of diastole".

They are produced due to pressure gradient between a high pressure area (Artery or Ventricle) and low pressure area (vein or right heart chamber)

Following are the causes of continuous murmur

1. Patient ductus arteriosus (PDA).
2. Rupture of sinus of valsalva - RSOV.
3. Aorto pulmonary window (AP Window).
4. Anomalous origin of left coronary aratery from pulmonary artery (ALCAPPA).
5. Surgical shunts - Blalock - Taussing in TOF.
6. Bronchopulmonary collaterals seen in TOF (Tetrology of fallot) tricuspid atresia, trances arteriosus.
7. Peripheral pulmonary artery stenosis.
8. Pulmonary embolism.
9. Pulmonary and coronary AV fistula.
10. Proximal pulmonary artery stenosis.
11. Intercostals AV fistula.
12. Collaterals in coarctation of aorta.
13. Venous hum.
14. Mammary souffle.

Site of murmur in continuous murmur

1. PDA                            - Left 2nd ICS (inter costal space)
2. AP window                 - left 3rd  ICS
3. Rsov                            - Left sterna border
4. Coronary AV fistula    -Left sterna border
5. Pulmonary AV fistula  - Left – 2nd ICS
6. Coarctation of Aorta     - Thoracic spine
7. Mammary soufflé         -Mammary and 2nd ICS

Differential diagnosis of continuous murmur

1. To and from murmur

1. They occur through single channel
2. Occupy mid systole and early part of idiastale
3. These murmurs want peak around  S2
4. Examples are : AS+AR, PAH + PR

Differentiation between continuous and To and Fro murmur

1. Continuous murmur
2. S2not heard
3. Uni directional
4. To & from murmur
5. S2heard Heard
6. Bi directional 

2. Systolic - Diastolic murmur

1. Murmur occur through different channels
2. Occupy systole and diastole
3. Does not peak around S2
4. Example : VSD + AR
5. Venous hum
6. Mammary Souffle

Types of continuous murmur

What are the non organic causes of cardiac murmur?

Non organic causes of cardiac murmurs are innocent murmurs, hemic murmurs and functional murmurs.

1.Innocent murmur

1. Also called as stills murmur
2. Commonly occur in children, disappear as the child grows.
3. Here heart and its valves are normal and resting cardiac output is also normal.
4. They are the most common cause of murmur

Mechanism of innocent murmur

1. Innocent murmur is produced due to following
2. In children there is hyperkinetic circulation due to increased heart rate
3. Increased resistance in pulmonary vascular bed.

What are the features of innocent murmur

1. They are localised systolic murmurs
2. Best heard over the pulmonary area
3. Better heard in supine position, murmur disappear in upright position
4. Murmur better heard after exercise, fever and crying
5. Heart sounds are normal, there is no thrill.

2.Physiologic murmur

1. When the murmur is related to increased cardiac output they are called physiologic murmur.
2. Here there is no organic disease.
3. They occur due to rapid early ejection of blood into aorta producing turbulence.
4. They are short systolic murmurs best heard in 2-4left intercostals space.
5. No radiation of murmur
6. Standing increases the physiologic murmurs

3.Haemic murmur

1. In patients with severe anemia an ejection systolic murmur may be heard in pulmonary area.
2. They are produced due to increased blood flow through the pulmonary artery and dilatation of pulmonary artery.
3. Correction of anemia result in disappearance of murmur.
4. Sometimes you may get a systolic thrill.

4.Functional murmur / flow murmur

1. At the site of production of murmur there is no organic heart disease.
2. Murmur is produced due to increased blood flow across the valve

Examples are 

1. Systolic mumur in pulmonary area in atrial septal defect (ASD)
2. Graham steel murmur of functional pulmonary incompetence
3. Functional aortic stenotic systolic murmur in AR (Aortic regurgitation)
4. Apical mid-diastolic murmur in AR (Austin flintic murmur)

Features of flow murmur 

1. Usually 
2. Localised
3. Systolic
4. Soft murmur
5. No significant postural change in murmur
6. Usually there is no thrill (Thrill may sometimes present)
7. There is no cardiomegaly
8. 2nd heart sound normal
9. Murmur disappear after the correction of increased flow

What are the named murmurs in cardiology?

Following are the named murmurs.

Still's Murmur

It is the innocent musical murmur ,seen in children.

Austin flint murmur

Mid diastolic murmur heard in apex in patients with aortic regurgitation.

Roger's murmur

It is the loud pansystolic murmur which is heard maximally at the left sternal border.  Heard in Ventricular septal defect (VSD).

Graham Steell murmur

Early diastolic murmur which is heard over Erb's point.Heard in pulmonic insufficiency, secondary to pulmonary hypertension and mitral stenosis.

Carey Coombs murmur

Mid diastolic murmur, heard in acute rheumatic valvulitis.

Rytands murmur 

Occur in complete heart block, this is a mid diastolic  murmur.

Docks murmur

This is a diastolic murmur, occur in left anterior descending (LAD) artery stenosis.

Mill wheel murmur 

Heard  due to air in right ventricular cavity following cardiac catheterization.

Cabot– Locke murmur

Diastolic murmur heard best at the left sternal border. heard in anemic patients .The murmur resolves with treatment of anemia.

Gibsons murmur

Continuous murmur heard in patent ductus arteriosis.Best heard at the left upper sternal border.

Key–Hodgkin Murmur

The Key–Hodgkin murmur is a diastolic murmur of aortic regurgitation .Hodgkin correlated this diastolic murmur with retroversion of the aortic valve leaflets ,seen  in syphilitic aortic regurgitation.