Continuous Murmurs

1. Continuous Murmurs Dr. R. Tandon Sitaram Bhartia Institute, New Delhi

2. Continuous Murmurs Defn. :- • A murmur starting in systole and going through the S2 in diastole. • A murmur present throughout the cardiac cycle : covers S1, S2 whole of systole and diastole, may be louder in systole or diastole.

3. Continuous Murmurs To & fro murmur :- A gap between the systolic and diastolic murmurs identifies two separate murmurs.

4. Continuous Murmurs Clinical Setting :- • Cyanotic or acyanotic. • Features of aortic run off - present, absent. • Features of hyperkinetic circ. - present, absent. • Cardiac chambers involved - all or partial.

5. Continuous Murmurs Acyanotic patients :-

6. Continuous Murmurs Cyanotic patients :- • Bronchial collat. in TOF physiology • PDA in TOF physiology • TAPVC • Pulm. AV fistula • PTA • Surgical shunts

7. Continuous Murmurs T.O.F. Physiology :- • Fallot’s tetralogy • Tricuspid atresia • DORV with VSD & PS/PA • TGA with VSD & PS/PA • Single vent. With PS / PA • Miscellaneous malpositions with VSD & PS/PA.

8. Continuous Murmurs PDA :- • Max intensity ULSB. Thrill ± • Systolic component louder, harsh broken into multiple clicks. • Diastolic component smooth and decrescendo. • Hollow character • Peaks at S2. • With PAH the diastolic component becomes shorter and may disappear . • May be palpable as systolic or cont. thrill.

9. S1 S2 S1 x CM

10. Continuous Murmurs Sinus of Valsalva fistula :- • Palpable as cont. thrill. • Loud grade V / VI. • May mask both S1 and S2 • Louder systolic component if VSD is present. • Louder diastolic component if AR is present. • Both VSD and AR may be present.

11. Continuous Murmurs Sinus of Valsalva fistula :- • Louder at RSB if in RA. • Louder at MLSB if in RV. Systolic component may be softer.

12. S1 S2 S1 CM

13. Continuous Murmurs Coron. AV fistulae :- • Relatively uncommon. • CM – 2 to 6 in intensity. • Mid to lower L, RSB. • Shunt size usually small. • Myocard. isch. uncommon

14. Continuous Murmurs Syst. AV fistulae :- • Intra cranial, intrahepatic, chest wall, abdomen, extremities. • CM. grade 2 to 4, midsystolic and diastolic peaks. • Depending on size of shunt; features of (a) aortic runoff (b) hyperkinetic circ state (c)  syst. ven. pr. (d) CCF specially neonates.

15. Continuous Murmurs Coarctation of the Ao :- • Systolic hypertension arms. • Systolic pr. diff between upper and lower segment – ejection syst. m. • Identical diast. pr. – no diast. m. • Cont. murmurs rare.

17. Continuous Murmurs Peripheral PS :- • Systolic gradient between proximal and distal segments – ejection syst. m. • No diastolic gradient - no diastol. or CM. • Rarely a diastolic gradient may be present & CM. • Acyanotic; PAH ±

19. Continuous Murmurs ALCAPA :- • High PA pr. perfuses LCA at birth. • ↓ PVR by 3-6 wks - myocard. ischaemia - anterolat. M.I. • Rarely good collaterals from RCA to LCA. - Present in childhood or later as a CM with small L to R shunt. • Dx. : Echo; RCA angio.

20. Continuous Murmurs AP Window :- • Relatively rare anomaly. • Usually large defects hence no CM. • 1-2% small. Atypical loud CM at 2 or 3 LICS. • Dx. Difficult. Site of m. unusual for PDA.

21. Continuous Murmurs MS with small ASD :- • Findings of MS. • Loud venous hum at ¾ RSB. • Louder in systole and expiration. • ? Is frequency higher.

22. Continuous Murmurs Venous hum :- • Common upto 6 to 8 yrs. • RSB, above clavicle, child sitting up. • Intensity  with inspiration. • May disappear : head to left, pressure above clavicle, lying down.

23. Continuous Murmurs TOF Physiology : • Severe obstr. Or PA. • Bronchial or Aorto pulm. collaterals perfuse PA. • Soft venous hum like CM. - Chest wall, interscapular area. • Large flow – louder m. - Mild cyanosis, LVE, Ao. runoff ±. • If PDA – usual site, m. can be atypical.

24. Continuous Murmurs TAPVC :- • CM : SSN, upper RSB,  flow, no obstr. • Infradiaphragmatic : CM in epigastrium, over the liver. • Obstr. site of PV entry to syst. V. / RA. • Features of severe PAH less common with CM.

25. Continuous Murmurs Pulm. AVF :- • Unexplained cyanosis. • Hemoptysis, embolism, brain abscess. • No CE, S1 & S2 normal, no m. • ECG normal. • Cont. m. over chest wall. • Chest x-ray may identify. • Contrast : left brachial inj.

27. Continuous Murmurs Persistent truncus :- • Ejection syst. m. ends before A2. • Truncal regurg. m. starts with A2. • Usually to & fro m. • Rarely PA osteal stenosis may result in CM. • Dx. : Echo Doppler

28. Continuous Murmurs VSD with AR :- • Pansyst. m masks S1 and S2. • AR m. starts with A2. • No gap at upper LSB. • Below Lt. clavicle m. character → to and fro.

29. Continuous Murmurs AS with AR :- to & fro. m. • AS m. ends before A2. • AR m starts from A2. • Gap easily appreciable should not be mistaken for a CM.

30. S1 S2 S1 XESM ARM

31. Continuous Murmurs Acyanotic patients : Physiol. effects • L → R shunt • Vol overload of circ. • Hyperkinetic circ. State ↓ SVR,  CO,  HR and SV •  Plasma vol. • Aortic runoff.

32. Continuous Murmurs Acyanotic patients : Physiol. effects •  syst. ven. pr. •  M VO2. •  Ao diast. Pr. Myocard. •  LV edp. Ischaemia •  diast. Filling time

33. Continuous Murmurs Cyanotic patients : Physiol. effects • Depend on anomaly • Pulm. AVF -  PVR in fistula -  PVR non affected area - R → L shunt – cyanosis - Potential for paradox embolism, brain abscess, hemoptysis.

34. Thank you

35. S1 S2 S1 CM S1 S2 S1 CM S1 S2 S1 X ESM ARM