Listening to the change in character behaviour and the intensity of the heart sounds and murmurs to physiological and pharmacological maneuvers AUSCULTATE WITH ALTERED HEMODYNAMICS ID: 774701
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Slide1
Dynamic Auscultation
Listening to the change in character,
behaviour
and the intensity of the
heart sounds and murmurs to
physiological and pharmacological
maneuvers…….
“AUSCULTATE WITH ALTERED HEMODYNAMICS”
Slide2Dynamic Auscultation
Source of murmur : Right Heart ~ Left Heart
Differentiate closely simulating murmurs
Outflow ~
Regurgitatnt
murmur
Differentiate flow murmurs from those of structural deformity : Austin Flint ~ MS
Differentiate Dynamic from Fixed Obstructions
Slide3Maneuvres
PHYSI(OLOGI)CALPostural change Supine / L Lateral Standing SquattingValsalvaHandgripCycle length change
PHARMACOLOGICAL
Amyl nitrite
Phenylephrine
Slide4Position
Left lateral
decubitus
: Augments the murmur of MS, MR, Austin Flint, MVP & S1, LV S3 & S4
Sitting & Leaning forward : ↑ AR murmur
Sitting with arms raised above the head : ↑ AR
Knee chest position : AR, Pericardial
Rub
Passive leg raising : ↑ VR >↑ Right Heart events
Slide5Slide6Slide7Slide8Slide9Respiration
Inspiration augments right sided events, as the venous return increases :
TR & TS , PR & PS murmurs ; RV S3,S4 & TV OS
S1 & S2 split widen.
Exception is PES – augmented in expiration
# Preferably quiet respiration
# Avoid apnea
# Listen the first few beats
# In erect posture if Venous pressure is high
Slide10Carvallo’s sign
Inspiratory accentuation of TR murmurEarly systolic murmur > holosystolicBlowing quality > musicalAbsent in severe RV failure associated TS is severeIf venous pressure is very high, listening in upright posture may help
Slide11Reversed Carvallo sign
HCM with RVO obstruction - ? ↑ VR > widened RVO
Slide12Slide13Slide14Slide15Respiration
Left sided events are better heard in expiration
MR, MS, AS & AR murmurs
LV S3 & S4, Mitral OS
Click & murmur of MVP occur later
@ PV – LA gradient increases > ↑ LV filling
@ Lung overlap decreases
@ Apnea for faint AR murmur
Slide16Slide17Slide18Pms
= mean systemic pressure;
Ppc
= pulmonary capillary hydrostatic pressure;
Ppi
= pulmonary interstitial hydrostatic pressure;
Ptm
= pulmonary capillary
transmural
pressure
Slide19Slide20Abrupt standing
S2 split which may be wide, may narrow down , while the fixed split may persist
A2 OS interval widens – differentiates from wide split of S2
All murmurs ( except MVP/HOCM) decrease
ESM of HOCM becomes louder and longer
Click occurs earlier, murmur becomes longer in MVP – loudness shows variable response
Slide21Slide22Slide23Isometric Hand Grip
HAND DYNAMOMETER
Slide24Slide25Physiological changes of ISOMETRIC HANDGRIP EXERCISE
Slide26Isometric Hand Grip
LV S3 & S4 get augmented
Murmurs of MR,AR,VSD intensify
Mitral
stenotic
murmur may augment
Systolic murmur of HOCM may diminish
Click & late
sytolic
murmur of MVP get delayed
Slide27Slide28Slide29Slide30Transient Arterial Occlusion
Slide31Slide32Squatting
Increased venous return and CO > augments most murmurs atleast initially (AS,PS,MR,AR,VSD) Right heart murmurs do so earlierIncreased ventricular volume > murmur of HOCM ↓ murmur of MVP ↓→Ejection murmur of TOF ↑
Slide33Slide34P Hanson
Br HeartJ7 1995;74:154
Slide35Central Aortic Pressure
T Murakami
AHJ 2002; 15:986–988
Slide36Hemodynamics of Squatting
T Murakami AHJ 2002; 15:986–988
Slide37T Murakami
AHJ 2002; 15:986–988
Slide38Slide39Slide40Valsalva Maneuver
Decreased venous return & CO, HR ↑; PP↓ S2 split narrows down, S3 & S4 diminish
Slide41Valsalva Maneuver
Reduces the intensity of all murmurs except that of HOCM & MVP
Murmur of HOCM intensifies as the LV cavity size decreases
Click occurs earlier, the murmur lengthens in MVP – may not intensify
During release, the intensity of right heart murmurs returns earlier - 1 to 3
vs
5 beats for left heart murmurs
Slide42VALSALVA STRAIN
Slide43ASD, HF, MS
Slide44Slide45Cycle Length VariationPost premature beat / Long cycle short cycle of AF
Post VPD / Long > Short cycle of AF :
Outflow murmurs ( AS/PS) accentuate
Regurgitant
murmurs do not change
Slide46Slide47Aortic
Stenosis
HOCM
Slide48Amylnitrite Inhalation
< 30
secs
: Systemic vasodilatation
30 – 60
secs
: ↑ HR & CO
Augments S1, LV S3 & S4, TV & MV OS, murmurs of AS,PS,TR & HOCM
A2 – OS may widen
Diminishes the murmurs of MR, AR, VSD, PDA & Systemic AVF
Click & Murmur of MVP occur earlier
Slide49Amyl Nitrite Inhalation
Augments DiminishesAortic stenosis Mitral regurgitationPulmonary stenosis TOFTricuspid regurgitation Mitral regurgitationMitral stenosis Austin FlintPulmonary regurgitation Aortic Regurgitaation
Slide50Phenylephrine
↑ BP & SVR ↓ CO & HR – last for 3-5mts
Reduces intensity of S1, A2-OS may widen
Augments the murmurs of VSD, PDA, MR, AR, TOF, Systemic AVF
Diminishes AS, MS & functional murmurs
ESM of HOCM diminishes
Click & murmur of MVP get delayed
Slide51Slide52↑
Afterload,↑Preload,↓Contractility
↓
Afterload,↓Preload,↑Contractility
Slide53Slide54Valslava
Slide55Slide56Slide57Slide58Slide59Slide60the caveats are………
Avoid dynamic auscultation in sick patients
When postures are changed, transition should be abrupt
Continuous auscultation is required, when
maneuvres
are being elicited
Concentrate on the first few cycles after
maneuvres
Realize that each
maneuvre
induces more than one alterations in
hemodynamics
Slide61Slide62Slide63Slide64Slide65Slide66Slide67Slide68Slide69Slide70