Organic diastolic murmurs. Features of noise detected during auscultation
It makes it possible to detect other sound phenomena, called noises. They occur when the opening through which blood flows is narrowed, and when the speed of blood flow increases. Such phenomena may be due to an increase in heart rate or a decrease in blood viscosity.
Heart murmurs divided into:
- murmurs generated within the heart itself ( intracardiac),
- murmurs outside the heart extracardiac, or extracardiac).
Intracardiac murmurs most often occur as a result of damage to the valves of the heart, with incomplete closure of their valves during the closure of the corresponding hole, or when the lumen of the latter is narrowed. They can also be caused by damage to the heart muscle.
There are intracardiac murmurs organic and functional(inorganic). The former are the most important diagnostically. They indicate anatomical lesions of the heart valves or the openings they close.
A heart murmur that occurs during systole, that is, between the first and second tone, is called systolic, and during diastole, i.e. between the second and the next first tone, - diastolic. Consequently, the systolic murmur coincides in time with the apex beat and the pulse on the carotid artery, and the diastolic murmur coincides with a large pause of the heart.
The study listening techniques for heart sounds it is better to start with systolic (with a normal heart rhythm). These noises can be soft, blowing, rough, scraping, musical, short and long, quiet and loud. The intensity of any of them can gradually decrease or increase. Accordingly, they are called decreasing or increasing. Systolic murmurs are usually decreasing. They can be heard during the entire systole or part of it.
listening diastolic murmur requires special skills and attention. This noise is much weaker in volume than systolic and has a low timbre, it is difficult to catch with tachycardia (heart rate more than 90 per minute) and atrial fibrillation (erratic contractions of the heart). In the latter case, long pauses between individual systoles should be used to listen for diastolic murmurs. Diastolic murmur, depending on the phase of diastole, is divided into three types: protodiastolic(decreasing; occurs at the very beginning of diastole, immediately after the second tone), mesodiastolic(decreasing; appears in the middle of diastole, a little later after the second tone) and presystolic(increasing; formed at the end of diastole before the first tone). Diastolic murmur may last throughout diastole.
Organic intracardiac murmur, caused by acquired heart defects, can be systolic (with insufficiency of the two- and tricuspid valves, narrowing of the aortic orifice) and diastolic (with narrowing of the left and right atrioventricular orifices, insufficiency of the aortic valve). A type of diastolic murmur is presystolic murmur. It occurs with mitral stenosis due to increased blood flow through the narrowed hole at the end of diastole with a contraction of the left atrium. If two noises (systolic and diastolic) are heard above one of the valves or holes, then this indicates a combined defect, i.e. valve insufficiency and narrowing of the hole.
Rice. 49. :
a, b, c - systolic, respectively, with insufficiency of two- and three-leaf valves, with stenosis of the aortic orifice;
d - diastolic with aortic valve insufficiency.
Localization of any noise heart corresponds to the place of the best listening to the valve, in the area of which this noise was formed. However, it can be carried out along the blood flow and along the dense muscle of the heart during its contraction.
systolic murmur bicuspid valve insufficiency(Fig. 49, a) is best heard at the apex of the heart. It is carried out towards the left atrium (II-III intercostal space on the left) and into the axillary region. This noise becomes clearer when holding the breath in the exhalation phase and in the position of the patient lying down, especially on the left side, as well as after exercise.
systolic murmur tricuspid valve insufficiency(Fig. 49, b) is well heard at the base of the xiphoid process of the sternum. From here it is conducted upward and to the right, towards the right atrium. This noise is better heard in the position of the patient on the right side when holding the breath at the height of inspiration.
systolic murmur narrowing of the aortic orifice(Fig. 49, c) is best heard in the II intercostal space to the right of the sternum, as well as in the interscapular space. It, as a rule, has a sawing, scraping character and is carried along the blood flow upward to the carotid arteries. This noise is amplified in the position of the patient lying on his right side with breath holding in the phase of forced exhalation.
Early systolic murmur
Mean systolic murmur (English):
Innocent systolic ejection murmur
Late systolic murmur
Late systolic murmur due to mitral valve prolapse
diastolic murmur at mitral stenosis, which occurs at the beginning or middle of diastole, is often better heard in the area of the projection of the bicuspid valve (the place where the third rib is attached to the sternum on the left) than at the apex. Presystolic, on the contrary, is better heard in the apex. It is almost never carried out and is especially well heard in the upright position of the patient, as well as after physical exertion.
diastolic murmur at aortic valve insufficiency(Fig. 49, d) is also auscultated in the II intercostal space to the right of the sternum and is carried out along the blood flow down to the left ventricle. It is often heard better at the 5th point of Botkin-Erb and increases in the vertical position of the patient.
Organic intracardiac murmurs, as already noted, may be the result of congenital heart defects(non-closure of the atrial - foramen ovale, ventricular septal defect - Tolochinov-Roger disease, non-closure of the arterial - ductus botalis, narrowing of the pulmonary artery).
At non-closure of the atrial opening systolic and dastolic murmurs are noted, the maximum audibility of which is detected in the region of attachment of the third rib to the sternum on the left.
At ventricular septal defect there is a scraping systolic murmur. It is auscultated along the left edge of the sternum, at the level of III-IV intercostal spaces and is carried out into the interscapular space.
At cleft ductus arteriosus(the aorta is connected to the pulmonary artery) a systolic murmur (sometimes with diastolic) is heard in the II intercostal space on the left. It is weaker heard over the aorta. This noise is conducted to the interscapular region closer to the spine and to the carotid arteries. Its peculiarity is that it is combined with an enhanced second tone on the pulmonary artery.
At narrowing of the pulmonary artery a rough systolic murmur is heard in the II intercostal space on the left at the edge of the sternum, little transmitted to other places; the second tone in this place is weakened or absent.
Noise may also result from expansion of the cavities of the heart without organic damage to the valve apparatus and the corresponding holes. For example, increased blood pressure in the system of a large circle of blood circulation (hypertension, symptomatic hypertension) can lead to an expansion of the cavity of the left ventricle of the heart and, as a result, to stretching of the left atrioventricular orifice. In this case, the mitral valve leaflets will not close (relative insufficiency), resulting in a systolic murmur at the apex of the heart.
Systolic murmur may occur with aortic sclerosis. It is heard on the right in the II intercostal space at the edge of the sternum and is due to the relatively narrow aortic orifice compared to its expanded ascending part. This noise increases with raised hands (symptom of Sirotinin-Kukoverov).
An increase in pressure in the pulmonary circulation, for example, with mitral stenosis, can lead to expansion of the orifice of the pulmonary artery and, consequently, to the occurrence diastolic Graham-Still murmur, which is auscultated in the II intercostal space on the left. For the same reason, with mitral stenosis, the right ventricle expands and relative tricuspid valve insufficiency occurs. At the same time, in the region of the IV intercostal space on the right, near the sternum and at the xiphoid process, a blowing systolic murmur is heard.
At acceleration of blood flow as a result of tachycardia, with a decrease in its viscosity due to anemia, with dysfunction of the papillary muscles (increase or decrease in tone), and in other cases, functional systolic murmurs may occur.
With insufficiency of the aortic valve at the apex of the heart, it is often audible functional diastolic (presystolic) murmur - Flint's murmur. It appears when the leaflets of the mitral valve are lifted by a strong stream of blood coming from the aorta during diastole into the left ventricle, and thereby cause a transient narrowing of the left atrioventricular orifice. Flint's murmur is heard at the apex of the heart. Its volume and duration are not constant.
Early diastolic murmur
Mean diastolic murmur (English):
Late diastolic murmur
Functional heart murmurs, as a rule, are heard in a limited area (best of all at the apex and more often on the pulmonary artery) and have a low volume, soft timbre. They are unstable, they can appear and disappear at different positions of the body, after physical activity, in different phases of breathing.
To extracardiac murmurs include pericardial friction rub and pleuropericardial murmur. Rubbing noise of the pericardium occurs during inflammatory processes in it. It is heard during both systole and diastole, it is better detected in the area of absolute dullness of the heart and is not carried out anywhere. Pleuropericardial murmur occurs during the inflammatory process of the pleura adjacent to the heart. It resembles the friction noise of the pericardium, but unlike it, it increases on inhalation and exhalation, and when holding the breath, it decreases or disappears altogether. Pleuropericardial murmur is heard on the left side
1. Definition. One of the frequent, in some cases very serious symptoms of heart damage are heart murmurs. At the same time, they can be heard in practically healthy people. Heart murmurs are called sound phenomena that occur in connection with the activity of the heart, longer than tones, and representing irregular aperiodic oscillations of various frequencies and loudness. Noises are usually longer than tones, often formed by oscillations of a higher frequency, reaching the order of 400-1000 Hz.
2. Noise analysis.
phase of occurrence: systole, diastole, systolic-diastolic interval.
epicenter of noise
The nature of the noise (expulsion, regurgitation)
intensity and timbre
holding
The state of heart sounds (amplification, weakening, accents, bifurcation of 3rd and 4th tones).
additional sounds: the sound of the opening of the mitral valve, inside the systolic click
Rhythm assessment
3. Additional diagnostic methods for heart murmurs.
ECG, PCG, sphygmography
Doppler echocardiography
X-ray of the chest, including contrasting the esophagus
angiocardiography, probing of the heart cavities
4. Basic heart murmurs
systolic ejection murmur
organic systolic ejection murmur in aortic stenosis
inorganic systolic ejection murmur in aortic stenosis
systolic ejection murmur in coarctation of the aorta
systolic ejection murmur in aneurysms of large vessels
systolic ejection murmur with stenosis of the orifice of the pulmonary artery
systolic ejection murmur in arterial stenosis
systolic murmur of regurgitation
Organic systolic regurgitation murmur in mitral insufficiency
Systolic murmur of regurgitation with relative mitral insufficiency
Systolic murmur of regurgitation in mitral valve prolapse syndrome
Systolic regurgitation murmur in tricuspid regurgitation
diastolic ejection murmur
diastolic murmur of mitral stenosis
diastolic murmur of "false" mitral stenosis
diastolic murmur in tricuspid stenosis
diastolic murmur of "false tricuspid stenosis"
Diastolic murmur of regurgitation
diastolic murmur in aortic insufficiency
diastolic murmur due to pulmonary valve insufficiency
Systolic-diastolic murmurs
systole-diastolic murmur with open ductus arteriosus
systole-diastolic murmur in arteriovenous lung aneurysm
systole-diastolic murmur with coarctation of the aorta
Heart murmurs not associated with damage to the valvular apparatus of the heart and blood vessels (extracardiac murmurs)
rubbing noise of the pericardium
Cardiopulmonary murmurs
pleural-pericardial murmurs
Vascular murmurs
arterial murmurs
venous murmurs
· Accidental noises
Functional noises
Noise formation mechanism. Blood inside the heart and blood vessels usually moves laminar, i.e., each of its particles passes equal and parallel paths in a certain period of time. Therefore, it moves silently. Noises appear in those cases when the laminar movement of blood is replaced by turbulent. The resulting eddies create oscillatory movements that we perceive as noise.
Turbulent motion occurs in the following four cases:
1) when blood flows through a narrow opening;
2) when two oppositely directed blood flows meet;
3) with the acceleration of blood flow;
4) with a decrease in blood viscosity.
The first two mechanisms occur with congenital and acquired heart defects, the second two - with an unchanged heart - due to tachycardia after exercise, with fever, hyperthyroidism, anemia.
Murmurs of an organic nature, i.e., associated with anatomical changes in the heart, are divided into: 1) expulsion murmurs, 2) filling murmurs, 3) reverse current murmurs (regurgitation).
Noises of exile occur when blood is pushed out with force through a narrow opening. This happens with stenosis of the mouth of the aorta or pulmonary artery in systole, with stenosis of the left and right atrioventricular openings in the last part of diastole. Ejection murmurs are usually the loudest and are often not only heard, but also palpated.
Filling noises usually low volume. They arise in connection with the turbulence of the blood flow when it moves from a narrower area to a wider one. The forces that move the blood, while small, are much weaker than with ejection noises. These noises quickly subside, as the pressure difference during the movement of blood levels off, the speed of blood movement, at first fast, approaches zero.
Reverse current noise (regurgitation) occurs due to valve insufficiency. In this case, two blood flows occur - one is normal, the other is pathological, reverse, which would not have happened if the valve had not been damaged. The meeting of two blood streams is marked by eddies and the appearance of sound waves. In terms of loudness, these noises occupy an intermediate position between the noises of expulsion and noises of filling. They are determined in case of insufficiency of the left and right atrioventricular valves and the aortic valve. They also occur with the relative insufficiency of these valves.
Of great importance for the diagnosis is phase where noise is heard. Systolic murmurs occur simultaneously or immediately after tone I and occupy all or part of the systolic pause. If there is no “gap” between the I tone and the noise, then the noise is called intervalless. If a light gap is caught between the I tone and noise, then such noise is called interval noise. The noise of expulsion is usually interval, the noise of the reverse current on the flap valves is non-interval. Systole is mentally divided into 3 segments - protosystole, mesosystole and telesystole. Noises of the reverse current are usually protosystolic, noises of ejection are predominantly mesosystolic, since the rate of ejection does not become maximum immediately, but after reaching the apogee it weakens again. Telesystolic murmurs are rare and occur when the valve leaflets prolapse.
If the noise occupies the entire systole, including both tones, then it is called pansystolic, if the noise does not include tones - holosystolic. Diastole is also mentally divided into 3 parts - protodiastole, mesodiastole and presystole. If a proto-diastolic murmur occurs simultaneously with the II tone, then it is called a non-interval proto-diastolic murmur. Such noises are most often heard with insufficiency of the semilunar valves of the aorta and pulmonary artery.
If between the II tone and protodiastolic noise the free interval is caught, then noise is called interval protodiastolic. Such sound phenomena are characteristic of narrowing of the atrioventricular orifices. Mesodiastolic murmurs, as well as interval protodiastolic murmurs, are observed with stenoses of the left and right atrioventricular orifices. Presystolic murmurs are usually associated with the expulsion of blood from the atria into the ventricles during active atrial contraction in atrioventricular stenosis.
Noises can be holodiastolic and pandiastolic, i.e. cover the entire diastole, including (or excluding) heart sounds. At last, some defects are characterized by the noise covering both a systole, and a diastole. Such noises are called continuous, or systole-diastolic. They occur with arteriovenous fistulas (for example, with patent ductus arteriosus).
epicenter the place where the noise is loudest is called. Usually the epicenter of the noise coincides with the place of listening to the valve where the noise occurs, sometimes the epicenter is displaced along the blood flow. So, the epicenter of noise in aortic stenosis is usually the II intercostal space to the right of the sternum, while the noise of aortic valve insufficiency is better heard at the Botkin-Erb point below and to the left of the place where the noise is generated.
As a rule, ejection noises are best heard at the point where they are formed, while the epicenters of reverse current noises are displaced. Determining the epicenter of noise is an important feature in the differential diagnosis of noise. This is also one of the characteristic features of organic noise; functional murmurs may not have an epicenter at all, they can be equally heard at any point of cardiac dullness.
The most important characteristic of noise, necessary for their differential diagnosis, is conducting. It was found that the murmur "carries" in the direction of the movement of the blood stream, due to which it can be heard not only at the point of the best auscultation of this valve, but also at a certain distance from it, even (and this is very significant) outside of cardiac dullness. Sound waves are especially well conducted through dense tissues - the bone tissue of the ribs and other parts of the skeleton. The nature of the conduction of noise - subject to certain rules:
a) noise is heard on both sides of the constriction;
b) noise is best conducted in the direction of blood flow;
c) the noise is also conducted better over the wider part of the tube.
Due to these patterns, noises that occur when the left atrioventricular valve is insufficiency are carried out to the axillary region, to the middle or even posterior axillary line, sometimes under the scapula. Systolic murmur in case of insufficiency of the left atrioventricular valve can also be carried upwards, to the points of Naunin and Botkin-Erb.
Noises that occur on the tricuspid valve can be carried out to the right half of the chest, but their distant conduction is rarely observed. They are never conducted into the axillary region, which makes it possible to distinguish sometimes very similar sound phenomena of defects of the left and right atrioventricular valves.
Systolic murmur in aortic stenosis is carried out in the right subclavian region, sometimes in the jugular fossa, very often on the vessels of the neck. A similar noise during narrowing of the trunk of the pulmonary artery is carried out to the left subclavian cavity.
Noise in aortic valve insufficiency, following the blood flow, is carried out to the Botkin-Erb point, where it is often louder than at the aortic point. Sometimes it can be caught at the top and even in the armpit.
The area of conduction of systolic murmur with non-closure of the interventricular septum is very large - almost the entire chest. Usually, as the distance from the place of its origin, the volume of the noise gradually fades away. If, when the phonendoscope capsule is moved, the noise increases again, then another noise is heard. The loudness of the murmur depends on numerous intracardiac and extracardiac causes. In addition to the true loudness of the noise, the concept of loudness depends on subjective circumstances, hearing acuity, the quality of the phonendoscope, etc. Basically, the patterns here are as follows: ejection noises are usually louder than reverse current noises and filling noises. With the onset of heart failure, the murmurs weaken. Organic noises are often louder than functional noises. All factors affecting the loudness of tones and classified as extracardiac (thickness of the chest, pericardial effusion, emphysema) also affect the loudness of heart murmurs. Since ancient times, doctors have distinguished between increasing (crescendo) and decreasing (decrescendo) noises.
In contrast to the idea of the form of noise, the concept timbre noise - purely auscultatory. It depends on the frequency response of the sound vibrations that make up the noise, and on the overtones included in it. On the diagnostic value of the timbre of noise, one can meet opposite points of view, up to the complete denial of the value of this feature.
The criteria for describing timbrashums are purely subjective. Often there are epithets - blowing, scraping, rough, soft. An experienced doctor "recognizes" certain defects by the characteristic timbre coloring (although this sign is not self-pressing). With stenosis of the aortic mouth, a lingering, rough, sawing systolic murmur is heard. The diastolic murmur of the stenosis of the left atrioventricular orifice of a low timbre, rumbling (“with the letter s ...”), differs significantly from the gentle, blowing, like breathing, murmur of aortic valve insufficiency. Quite characteristic of a low tone is the noise of insufficiency of the right atrioventricular valve, resembling buzzing rales in the lungs. A special "buzzing" timbre often has a systolic-diastolic murmur in case of patent ductus arteriosus.
It is believed that if two noises of different timbres are detected at different points, then the mechanisms of their occurrence are different.
Occasionally, noises, due to the significant proportion of regular sinusoidal oscillations in their composition, acquire a musical character, as from the vibration of a string. musical we call those heart murmurs that are predominantly regular sinusoidal oscillations. Such murmurs may be organic, functional, or accidental, occurring in systole, diastole, or both. They can be formed by vibrations of different frequencies (low-frequency musical noises - (150-100 Hz or less and high-frequency musical noises - 300-500 Hz or more). The latter differ even when listening to a whistling or squeaky character. The reasons for the "musical" timbre are numerous and not are always quite clear (The cause of such noises can be both insignificant changes in the structure of the heart valves, the location of the chordal filaments in relation to the blood stream, and serious pathological processes in the heart - perforation of the valves, rupture of the chordal filaments, etc.) An important role is played by the phenomena of resonance in the site of origin of the sound and in the surrounding organs.
Correct evaluation of murmurs is sometimes impossible with normal auscultation. A number of techniques are proposed that are used in unclear cases. Usually all noises are best heard in the supine position. The murmur of aortic valve insufficiency is often easy to hear in the standing position, and mitral murmurs are sometimes detected only in the supine position on the left side.
The Kukoverov-Sirotinin technique is known: in a standing position, when the head is pulled back and the arms are raised up, the systolic murmur in aortic stenosis, aortitis and atherosclerosis of the aorta becomes louder, the accent of the II tone over the aorta increases. Protodiastolic murmur in aortic valve insufficiency sometimes has to be heard with a sharp torso forward. With fuzzy results of the Kukoverov-Sirotinin technique, it is possible to supplement the study with F. A. Udintsov’s technique: tilting the torso forward.
It is important to investigate the features of noise changes in different phases of respiration. It is usually most convenient to listen during exhalation. During expiration, the blood flow to the left ventricle increases somewhat and all the phenomena that occur in the left half of the heart increase. During inspiration, the volume of blood in the right half increases due to the action of the suction force of the chest. Therefore, all sound phenomena on inspiration increase over the valves of the right half of the heart and weaken over the left half of the heart.
Physical activity causes tachycardia, but at the same time increases the speed of blood flow, and therefore listening to the heart after small physical exertion often provides additional information. Usually all tones and noises of the most various genesis amplify.
All noises are divided into 4 groups according to their clinical significance:
1) organic noises,
2) organofunctional noises,
3) functional noises,
4) accidental noises.
organic noises due to congenital or acquired deformation of the heart valves such as valve insufficiency or orifice stenosis, as well as developmental anomalies in the form of shunts between the right and left parts of the heart.
Organo-functional noises occur in the absence of pathological processes on the valves, due to the expansion of cavities in lesions of the heart muscle - an inflammatory, sclerotic or dystrophic nature. This causes expansion of the valve ring and normal valves are unable to close the hole when they close. In such cases, one speaks of relative valve insufficiency. The capacity of the cavity during its expansion can increase so much that the normal opening is too narrow to pass all the blood accumulated in the cavity during the systole of the corresponding part of the heart. In such cases, we are talking about relative stenosis of the opening without obvious anatomical signs of its narrowing. The sound picture of organic and relative defects is very close and it is possible to distinguish them only on the basis of the totality of clinical signs of the disease. Sometimes organo-functional noises appear when the heart muscle is weakened and disappear or weaken when its function is restored.
Functional noises (FS) occur in an intact heart due to an acceleration of blood flow, a decrease in blood viscosity in anemia, a change in the tone of the papillary muscles, and for a number of other reasons that have not yet been clarified. In most healthy people and, in particular, in most young men, functional systolic murmurs are heard over the apex and pulmonary artery. The difference between functional noise from organic and organo-functional is one of the most important tasks in auscultation. Functional noises are usually not loud. In most cases, they are heard in the mesocardial region, do not have a clear epicenter. They are not carried out beyond cardiac dullness. Functional systolic murmurs over the apex are most often interval proto- or mesosystolic.
Indirect auscultatory symptoms are also used: the absence of a weakening or unusual amplification of the first tone, the absence of an accent of the second tone over the pulmonary artery and aorta indicates the functional nature of the noise. Other, non-auscultatory symptoms should not be neglected: normal palpation data, the absence of displacement of the borders of the heart also indicate the functional nature of the noise.
Additional tests - with a change in body position, with physical activity - are not essential for distinguishing organic and organ-functional noises from functional ones. Functional noises are heard in 85% of children and adolescents. At this age, a normal three-part melody, a soft systolic murmur over the apex that does not radiate to the axillary region, and often a local blowing murmur in the region of the projection of the pulmonary artery are characteristic. As you grow and mature, this noise disappears.
FS in various diseases.
These are noises in patients with certain diseases, including those of the heart, but with unchanged valves; occur in patients with relative valve insufficiency or relative stenosis of the holes, with changes in blood flow and rheological properties of the blood.
Most often, relative mitral valve insufficiency develops, the cause of which is pathological conditions that occur with dilation and hypertrophy of the left ventricle, which leads to expansion of the fibrous ring of the left atrioventricular orifice and incomplete closure of the valve leaflets during systole. This happens with myocarditis, dilated cardiomyopathy, arterial hypertension of any origin, aortic heart disease. A systolic murmur is heard with an epicenter at the apex, most often blowing, not very loud, as a rule, not "musical". Differential diagnosis with organic insufficiency is based on the analysis of the clinic of the disease (no signs of a rheumatic process, bacterial endocarditis), echocardiography data. Often functional systolic murmur is heard on the aorta in atherosclerosis. This noise is weaker than with organic stenosis, sometimes it is necessary to use additional techniques to detect it (noise appears or intensifies when hands are raised - a symptom of Kukoverov-Sirotinin), the noise is practically not carried out on the vessels of the neck.
The causes of systolic functional murmur may be an acceleration of blood flow and a decrease in blood viscosity. This is often observed in patients with anemia, thyrotoxicosis, sometimes with fever. The systolic murmur of this genesis can be heard at many points, it is usually gentle, blowing, on FCG it occupies only part of the systole. As the patient's condition improves, the blood flow velocity decreases, the noise weakens and may disappear altogether. Diastolic functional murmurs are very rare. Graham-Steele murmur is auscultated in patients with severe pulmonary hypertension with mitral stenosis and is due to relative insufficiency of the pulmonary artery valves. At the apex in patients with aortic insufficiency, a diastolic functional Flint murmur is sometimes heard. It occurs as a result of relative stenosis of the mitral orifice, when one of the valves, as it were, "covers" it under the influence of a jet of blood regurgitation from the aorta. Flint's murmur is proto-diastolic, very gentle, does not combine with other signs of mitral stenosis, it cannot be registered on the FCG (see Table 1 "Appendices").
"Innocent" FS in practically healthy people.
"Innocent" functional murmurs are always systolic, heard more often at the apex and pulmonary artery. Their mechanism is completely unclear, since they are detected in practically healthy individuals; in recent years, based on echocardiography data, they have been associated with dysfunction of the chordal filaments. To classify the noise as "innocent", you need to make sure that you have an intact, healthy heart. The boundaries of the heart are not changed, the tones are clear. Instrumental studies, as a rule, do not reveal a pronounced pathology, although some hemodynamic changes may be (hyperkinetic type of hemodynamics). The murmur is usually very short, not loud, better heard in the supine position, disappears in the upright position. Unlike organic and functional muscle noises, "innocent" noise after exercise may disappear, and reappear after a while. In most cases, the usual clinical examination allows us to classify the noise as "innocent". However, in situations requiring expert assessment (conscription into the army, admission to certain types of work), an additional examination is necessary.
Accidental noises can only be defined negatively. This includes noises that do not fit into the first two groups. The place and mechanism of their occurrence cannot be confidently identified in each individual case. Most of the systolic accidental murmurs can be likened to pipe leakage murmurs (Bondi) and attributed to the formation of eddies, due to the inconsistency of ventricular outflow conditions, which is already normal. However, not all accidental sound phenomena can be associated with systolic blood flow from the ventricles. The possibility of noise in the ventricles themselves should also be considered.
In diastole, inorganic murmurs are also sometimes found, which, however, can often be associated with functional stenosis of the atrioventricular orifices or with functional insufficiency of the semilunar valves and, according to the above definition, should be classified as functional. If the mechanism of noise remains not clear, then it is necessary to speak about accidental diastolic noise. Although diastolic accidental murmurs (as opposed to systolic murmurs) are relatively rare, it is still not fair to say that diastolic murmurs always indicate an organic lesion of the valves. This statement has been emphasized in the past and has survived in some textbooks to this day.
With the progress of our knowledge about the mechanism of noise generation, the group of accidental noises will decrease in weight more and more. However, we will never find the causes of all accidental noises, since, most likely, there is no single reason due to the fact that a large number of the most diverse changes in blood circulation can cause the appearance of noises. Spitzbarth, in particular, recently showed this based on a study of the peripheral circulation. At the same time, it turned out that accidental noise was found in all persons with a relatively large stroke volume and a wide peripheral channel, i.e., low peripheral resistance. As indicators of this state of hemodynamics, a steep anacrota, a short plateau and a high position of the incisura of the carotid sphygmogram were considered.
In children, accidental systolic murmurs are mandatory. With proper registration technique, a weak systolic murmur is found in most adults. The mechanism of occurrence of systolic murmur, both in normal valves and in affected ones, is the same, there is only a quantitative difference between these murmurs.
It follows from the above that there are no reliable auscultatory and phonocardiographic signs of accidental systolic murmurs. The place of the best perception of these noises is located at the level of the second fourth intercostal space at the left edge of the sternum, but some of them are best heard at the apex. Accidental noises are usually weaker than organic ones and are worse conducted. But, as is known, the intensity of the noise itself cannot serve as a decisive feature that allows us to consider the noise
accidental or organic. In about two cases out of three, the noise is much weaker when the patient is sitting or standing, but there may be an inverse relationship, or the intensity of the noise does not depend on the position of the body at all. After exercise or inhalation of amyl nitrite, the intensity of accidental systolic murmur in most cases increases, with the Valsalva maneuver and with extrasystoles it decreases.
If we consider heart murmurs from the position of phonocardiography, then we will pay attention to their following forms (Fig. 1 "Appendices").
It should be noted that the definition of "crescendo" and "decrescendo" murmurs is simplified, since each heart murmur, strictly speaking, must have a period of increase and a period of attenuation. In relation to the total duration of the noise, however, these periods can be very short and are neglected in determining the nature of the noise. In some cases, heart sounds are superimposed on the beginning and end of the noise, which are indistinguishable either on the phonocardiogram or when listening. In addition, these characteristics depend on various factors (see tab. 2 "Appendices").
Extracardiac (extracardiac) murmurs: Noises perceived over the heart are naturally associated with the hemodynamic processes occurring in it. However, it should be taken into account that extracardiac sound vibrations can be detected above the heart and nearby organs, synchronous with the cardiac cycle and therefore similar to true heart murmurs. In terms of differential diagnosis, it is very important to be able to distinguish between them. Of course, the noise in the vessels lying near the heart, as, for example, in the patent ductus arteriosus, are also, strictly speaking, extracardiac. But usually I call extracardiac only those noises that are not associated with the movement of blood. Thus, these noises arise in connection with cardiac activity, however, not in the heart itself, but in the organs surrounding it: in the adjacent pleura, in the lungs, in the pericardium. They appear with dry fibrinous pericarditis: the leaves of the pericardium, due to the imposition of fibrin, lose their smoothness and, when they are mutually displaced, sounds of different volume and duration occur. Usually pericardial rub auscultated within absolute cardiac dullness. In its timbre, the pericardial friction noise resembles the creaking of the skin or the crunch of snow. He can be very quiet and gentle. The most characteristic feature of the pericardial friction noise is its incomplete coincidence with the heart melody, it happens both in systole and in diastole, the time of listening to it changes from cycle to cycle. Friction noise occurs mainly at the beginning of systole and the beginning of diastole, sometimes - at the presystole. The pericardial presystolic murmur differs from the presystolic murmur of mitral stenosis by a relatively early onset and by the fact that it often ends before the I tone, including in cases where atrioventricular conduction is not slowed down. We have already mentioned the higher-frequency composition of the friction noise. The place of best perception may be different, sometimes changing in the same patient from day to day. The transition of a pericardial friction murmur from systole to diastole or vice versa is proof that this is not a normal endocardial murmur. While pericardial friction murmurs are rare, extracardiac systolic murmurs are very common and important as they lead to misdiagnosis of cardiac malformations.
The friction of the sheets of the pericardium against each other or the friction of the pericardium against the pleura is not associated with changes in pressure inside the heart and the resulting "play" of the valves. As kymographic studies clearly show, the heart at the critical point between contraction and relaxation is not in complete rest, but continues pendulum and rotational movements. It also shifts due to breathing. The intensity of the pericardial friction noise mostly depends on the phases of respiration: in some cases, the noise is more intense on inspiration, in others - on expiration. A reliable sign is a sudden increase or decrease in amplitude, i.e., a very pronounced variability of the noise. At the same time, in separate cycles, the location of the maximum and minimum of noise can be completely different. In some cases, the noise is more intense when the patient is lying, in others, on the contrary, when he is sitting.
Residual effects of pericardial friction murmur, sometimes persisting throughout life, are manifested by a coarse late systolic murmur with or without a systolic click. With graphic registration, cardiac and vascular murmurs look like more or less regular shapes (triangles, rectangles, rhombuses). Extracardiac noises do not keep within these schemes; it is clearly seen that they arise out of connection with the movement of blood in the heart or in large vessels. These noises are characterized by sudden increases and decreases in amplitude, often they are not associated with periods of cardiac activity. Sometimes there are also no maximum or minimum noise constants for all cycles. Auscultatory extracardiac noise corresponds to a rough, "jumping" nature of the sound.
The main distinguishing features of pericardial friction noise are:
1. It is heard superficially, as if at the very ear, sometimes it is determined by touch.
2. Friction noise does not coincide with the phases of cardiac activity and may consist of several fragments.
3. He is not carried beyond the dullness of the heart ("dies at the place of his birth").
4. It does not have a specific epicenter, but is determined over the entire area of absolute cardiac dullness.
5. Increases when the torso is tilted forward and when pressed with a stethoscope capsule.
6. Often unstable, within a short time it can disappear and appear, change its localization and volume.
Pleural-pericardial murmur occurs with the development of fibrinous pleurisy in areas adjacent to the pericardium, where an inflammatory process is also observed. In terms of their timbre, pleuro-pericardial murmurs are similar to pericardial friction murmurs and pleural friction murmurs, i.e., they resemble the crunch of snow. However, they are always localized along the edge of relative cardiac dullness, more often the left, and may increase during inspiration, when the edge of the lung is more tightly pressed against the pericardium. However, in time they coincide with the phases of cardiac activity. Quite often at the same time it is possible to listen to a pleural rub in areas of the chest distant from the heart.
Cardiopulmonary noises occur in those parts of the lungs that are adjacent to the heart, they are caused by the movement of air in the lungs under the influence of a change in the volume of the heart. These noises are weak, blowing, similar to the nature of vesicular respiration, but coincide with cardiac activity, and not with the phases of respiration.
Depending on inspiration or expiration, cardiopulmonary murmurs change dramatically or even disappear. Since they can occur in healthy individuals, it is important to remember that cardiopulmonary murmurs can be mistaken for intracardiac and lead to misdiagnostic inferences.
These are sounds of great length, which differ from tones in duration, timbre, and loudness. The mechanism of formation - arise due to the turbulent movement of blood. Normally, blood flow in the heart and cavities is laminar. Turbulence appears when the normal ratio of three hemodynamic parameters is violated: the diameter of the valve openings or the lumen of the vessels, blood flow velocity, and blood viscosity.
The reasons:
1. morphological (anatomical changes in the structure of the heart, valvular apparatus, blood vessels). May be in the form:
Stenosis (narrowing)
Valve insufficiency
Congenital defects in the structure of the heart
2. hemodynamic factors (the presence of a large pressure gradient between the cavities of the heart or the cavity of the heart and the vessel).
3. rheological - a decrease in blood viscosity - anemia, polycythemia.
Noise classification:
at the place of formation: intracardiac, extracardiac, vascular.
due to the formation of intracardiac - organic and functional.
in relation to the phases of the cardiac cycle - systolic and diastolic.
due to the occurrence - stenotic, regurgitation.
Allocate proto-, pre-, mesosystolic (-diastolic), pansystolic (-diastolic).
in shape - decreasing, increasing, diamond-shaped (increasing-decreasing) and decreasing-increasing.
Organic intracardiac murmurs.
They are caused by damage to the valvular apparatus of the heart, that is, narrowing of the valve openings or incomplete closure of the valves. In this case, incomplete closure can be caused by an anatomical lesion or functional impairment, so they are divided into organic and functional.
Organic noises are the most important, as they are a sign of an anatomical lesion of the valvular apparatus of the heart, that is, they are a sign of heart disease.
When listening to noise, its analysis is carried out in the following sequence:
The ratio of noise to the phases of the cardiac cycle
Noise epicenter
Relationship with heart sounds
Irradiation zone
Intensity, duration, pitch, timbre.
Organic systolic murmurs are heard in the case when, being expelled from the ventricle, the blood meets a narrow opening, passing through which it forms a noise. Systolic organic noises are divided into regurgitation and stenotic.
Regurgitation occur when:
mitral valve insufficiency - heard at the apex of the heart, accompanied by a weakening of the first tone and an accentuation of the second tone on the LA. It is well carried out in the axillary fossa, it is better heard in the position on the left side in a horizontal position. Decreasing in character, closely related to tone I. The duration of the noise depends on the size of the valvular defect and the rate of contraction of the left ventricular myocardium.
tricuspid valve insufficiency. The same picture is heard on the basis of the xiphoid process.
ventricular septal defect - a rough, sawing noise. It is best heard along the left edge of the sternum in the 3rd-4th intercostal space.
Stenotic systolic murmur.
aortic stenosis.
Auscultated on the 2nd intercostal space at the left edge of the sternum. Eddy turbulent currents are formed on the aorta. Irradiates with blood flow to all major arteries (carotid, thoracic, abdominal aorta). Auscultated in the supine position on the right side. Rough, sawing, waxing and waning noise.
stenosis of the pulmonary artery - in the 2nd intercostal space on the left, the properties are the same.
Organic diastolic murmurs.
It is heard in those cases when, during diastole, blood entering the ventricles meets a narrowed opening on its way. They are most pronounced at the beginning and, unlike systolic ones, they do not radiate.
protodiastolic a murmur is heard above the apex of the heart, is a sign of mitral stenosis, accompanied by an increase in the first tone, accentuation, splitting or bifurcation of the second tone on the LA. Mitral valve opening tone. With mitral stenosis, a diastolic murmur is heard at the end of diastole, before the I tone. The mechanism of formation is associated with the flow of blood into the cavity of the left ventricle through the narrowed mitral opening in the phase of atrial systole.
If the diastole is short, then the interval is shortened and the noise is decreasing-increasing.
Diastolic murmur at the base of the xiphoid process is a sign of tricuspid valve stenosis.
Based on the heart, a diastolic murmur can be heard with aortic or pulmonic valve insufficiency. With insufficiency of the aortic valve, the I tone is weakened, the II tone on the aorta is weakened.
Diastolic murmur in aortic insufficiency is better heard at the Botkin point, with a more pronounced spanking - in the 2nd intercostal space to the right of the edge of the sternum. Diastolic murmur in the 2nd intercostal space on the left is a sign of LA valve insufficiency. Organic malformation is extremely rare, more often it is a sign of LA valve insufficiency, which develops with dilatation of the LA mouth with an increase in pressure in the systemic circulation - functional diastolic Graham-Still murmur.
If there is both systolic and diastolic murmur at the first point of auscultation, one should think about a combined heart disease (a combination of stenosis and insufficiency).
When auscultation of noise can not be carried out in only one position. It is necessary to listen to the patient in a vertical position, horizontal and in certain individual positions, in which the blood flow velocity increases and, therefore, the noise is better determined. Increased noise in aortic insufficiency with arms thrown behind the head - SpSirotinin-Kukoverov.
During auscultation of noise, attention is drawn to the timbre, the shades of noise - soft, gentle, scraping, sawing, chondral squeak- at the apex of the heart in the presence of anomalies of the chords or tearing of the tendon filaments.
functional noise.
They are heard in pathological conditions that are not associated with anatomical changes in the valvular apparatus. Sometimes they can be heard normally. The reasons:
violation of hemodynamics, which leads to an increase in blood flow velocity (physiological and emotional stress, fevers. Noises that are heard in adolescents are physiological youthful noises, the result of a discrepancy between the growth of blood vessels in length and width).
violation of the rheological properties of blood - anemia (decrease in blood viscosity, adhesion of elements in the blood to each other, the appearance of turbulent currents).
weakening of the tone of the papillary and circular muscles - with a decrease in the tone of the papillary muscles, tendons of the chord and the leaflet of the mitral valve and the tricuspid valve. It sags into the atrium, incompletely closing the AV foramen. So during atrial systole, blood enters the atrium from the ventricle, so functional noises are heard. The circular muscle covers the AV ring, when stretched - the relative insufficiency of the valve.
stretching of the valve opening during dilatation of the cavities of the heart or blood vessels (aorta, LA). The reason is myocarditis, myocardial dystrophy, dilated myocardiopathies.
Functional noises are divided into myocardial and vascular, physiological (youthful) and pathological. The vast majority of functional murmurs are systolic. Only 2 functional diastolic murmurs are known - diastolic Grahamm-Still murmur(relative insufficiency of LA valves), noiseFlint- at the top. The mechanism of its formation is associated with the development of functional mitral stenosis in aortic valve insufficiency. It is not accompanied by the appearance of a mitral valve opening tone, the quail rhythm is not auscultated.
Differences between functional and organic noises.
functional are heard more often in systole
they are heard over the top and LA
inconstant: disappear and appear, arise in one position and disappear in another.
never occupy the entire systole, are more often heard in the middle, are not associated with heart sounds.
are not accompanied by changes in the volume of tones, splitting and other signs of heart defects.
do not have characteristic irradiation
in volume and timbre they are softer, gentle, blowing.
not accompanied by cat purring
physiological amplify during exercise, organic noise does not change
extracardiac murmurs.
Noises that occur independently of the operation of the valvular apparatus and are mainly due to the activity of the heart. These include pericardial rub, pleuropericardial murmur, cardiopulmonary murmurs.
Rubbing noise of the pericardium occurs when:
the presence of irregularities, roughness on the surface of the sheets of the pericardium: with pericarditis, tuberculosis, leukemic infiltration, hemorrhage into the thickness of the sheets of the pericardium, uremia - the death knell of uremic.
increased dryness of the sheets of the pericardium - dehydration with persistent vomiting, diarrhea.
Signs:
auscultated over the zone of absolute cardiac dullness
heard in both systole and diastole
does not necessarily match with the (..) loop phase.
is not carried out in other places, is heard only in the place of education.
aggravated by pressure with a stethoscope and by tilting the torso forward or in the knee-elbow position.
Pleuropericardial murmur auscultated with inflammation of the left pleura, covering the top and left. With the contraction of the heart due to a decrease in its volume, the lungs expand at the point of contact with the heart, so a friction noise against the pleura is heard. He is auscultated on the left edge of the relative cardiac dullness. Increases with deep breathing, accompanied by the presence of pleural friction noise in other places remote from the heart.
Cardiopulmonary murmur occurs near the left border of the heart, is determined in the form of weak sounds heard during systole. This noise is due to the fact that during systole the heart decreases in volume and makes it possible to straighten out the area of the lung adjacent to it. The expansion of the alveoli in connection with the inhalation of air forms this noise. It is heard more often to the left border of relative cardiac dullness with cardiac hypertrophy or an increase in the rate of myocardial contraction.
Vascular murmurs. After palpation of the arteries, they are auscultated, they try not to squeeze the wall of the arteries, since normally, without pressure with a stethoscope, I tone is heard over the carotid, subclavian, and femoral arteries. Normally, no tones are heard on the brachial artery. In pathological conditions, tones begin to be heard over smaller vessels. In case of insufficiency of the aortic valve above the large arteries (femoral), instead of the I tone, the II tone is heard, which is called double tone Traube. When listening to the femoral artery with pressure with a stethoscope, instead of I tone, II can be heard - double Vinogradov-Durazier noise. If noise is heard over any artery without pressure, this is a sign of a sharp narrowing of the artery - atherosclerosis, congenital anomaly or compression from the outside, or aneurysms.
Auscultation of the arteries.
Renal arteries - with narrowing, vasoadrenal (renovascular) renal arterial hypertension develops. Auscultated near the navel, absent 2 cm from it and along the edge of the rectus abdominis muscle at the level of the navel.
The celiac artery is heard just below and to the right of the xiphoid process.
Normally, neither tones nor murmurs are heard over the veins. With severe anemia as a result of a sharp dilution of blood over the jugular veins, wolf noise.
Auscultation of the thyroid gland.
Normally no murmurs are heard. With thyrotoxicosis and thyroiditis, due to an increase in the number of vessels, unevenly expanding arteries in the gland tissue and an increase in blood flow velocity, a systolic murmur is heard.
systolic heart murmur diastolic
Early diastolic (proto-diastolic) murmur
Early diastolic (protodiastolic) noise (Fig. 227.4, B) begins shortly after the second tone, as soon as the pressure in the ventricle becomes lower than in the aorta or pulmonary artery. High-frequency noise is characteristic of aortic insufficiency and pulmonary valve insufficiency caused by pulmonary hypertension. This noise is decreasing, as the pressure gradient between the aorta (or pulmonary artery) and the ventricle gradually decreases.
To catch a faint high-frequency murmur of aortic insufficiency, it is necessary to ask the patient to sit down, lean forward, exhale completely and hold his breath. The phonendoscope is strongly pressed against the chest wall at the left edge of the middle third of the sternum. The noise of aortic insufficiency increases with a sharp increase in blood pressure (hand press) and weakens with its decrease (inhalation of amyl nitrite).
Diastolic murmur in congenital pulmonary valve insufficiency is low- or medium-frequency (the pressure gradient between the pulmonary artery and the ventricle is small) and does not occur at the time of valve closure, but a little later.
Early diastolic (protodiastolic) murmur occurs with aortic valve insufficiency and pulmonic valve insufficiency. Usually, the murmur is high-frequency, decreasing, especially in chronic aortic insufficiency. Its duration indicates the severity of the lesion: the smaller it is, the more severe the aortic insufficiency.
The murmur of aortic insufficiency is most often, but not always, best heard in the second intercostal space at the left edge of the sternum.
With valvular disease (rheumatic disease, congenital bicuspid valve, infective endocarditis), the noise spreads along the left edge of the sternum to the apex, with damage to the aortic root (aortoannular ectasia, dissecting aortic aneurysm) - along the right edge of the sternum. Sometimes the noise is heard only when bending forward at the height of full exhalation, when the aortic root approaches the anterior chest wall. In severe aortic insufficiency, a low-frequency presystolic murmur at the apex (Flint's murmur) is sometimes heard, it occurs due to the fact that during atrial systole, an oncoming stream of aortic regurgitation hits the anterior leaflet of the mitral valve and causes it to tremble. Flint's murmur must be distinguished from mitral stenosis murmur. In the absence of heart failure, severe chronic aortic insufficiency is accompanied by symptoms of reverse diastolic blood flow in the aorta: high pulse pressure and high rapid pulse (Corrigen's pulse).
In acute aortic insufficiency, the noise is noticeably shorter, its frequency is lower. With tachycardia, this noise is difficult to hear. There may also be no symptoms of reverse diastolic blood flow in the aorta, because in a stubborn left ventricle, diastolic pressure rises very quickly and the pressure gradient between the aorta and the left ventricle disappears.
In pulmonic valve insufficiency, a murmur (called a Graham Still murmur) begins simultaneously with an increased (palpable) pulmonary component of the II tone, is best heard over the pulmonary artery, and is conducted along the left edge of the sternum. Usually the noise is high-frequency decaying. It indicates severe pulmonary hypertension with a high diastolic pressure gradient between the pulmonary artery and the right ventricle. The murmur increases with inspiration, which distinguishes it from the murmur of aortic insufficiency. There are often symptoms of right ventricular pressure and volume overload.
In mitral stenosis, a diminishing early diastolic murmur along the left sternal border is most often caused by concomitant aortic regurgitation rather than pulmonic valve insufficiency, although such patients have pulmonary hypertension.
Pulmonary valve insufficiency is not necessarily caused by pulmonary hypertension: it can also be congenital, and occasionally this valve is affected by infective endocarditis. Noise begins simultaneously with the pulmonary component of the II tone or immediately after it. In the absence of pulmonary hypertension, the murmur is low-pitched and less loud than the classic Graham Still murmur.
Heart: mesodiastolic murmur
Mesodiastolic noise occurs during early diastolic filling (Fig. 227.4, D) due to a mismatch between the size of the openings of the mitral or tricuspid valve and the volume of blood flow through them. The duration of the murmur is much better than the loudness in reflecting the severity of the stenosis: the more severe the stenosis, the longer the murmur, while with normal cardiac output, the murmur can be quite loud (grade III) despite a slight stenosis. Conversely, the murmur may decrease and even disappear in severe stenosis if cardiac output is significantly reduced.
A low-pitched murmur of mitral stenosis immediately follows the opening of the mitral valve. It is best to listen to it at the top with a stethoscope socket in the position of the patient on the left side; sometimes that's the only way you can hear that noise. To strengthen it, you can resort to a small physical activity in the supine position or inhalation of amyl nitrite.
With tricuspid insufficiency, the noise is heard in a rather limited area at the left edge of the sternum, it intensifies on inspiration.
A middiastolic murmur is most commonly caused by mitral stenosis or tricuspid stenosis or increased blood flow through the AV valves. A classic example is rheumatic mitral stenosis (Fig. 34.1, E). If there is no pronounced calcification of the leaflets, then a loud (clapping) I tone and a click of the opening of the mitral valve are heard, followed by a murmur. The higher the pressure gradient between the left atrium and the ventricle, the shorter the interval between the second tone and the opening click. Noise - low-frequency, it is best of all auscultated by a stethoscopic bell of a stethophonendoscope at the top. The murmur increases in the left lateral position, and the duration of the murmur, rather than its loudness, reflects the severity of the stenosis: a continuous murmur indicates that a pressure gradient between the left atrium and ventricle is maintained for most of diastole. Against the background of sinus rhythm, a presystolic increase in noise is often determined (Fig. 34.1, A), corresponding to atrial systole.
With tricuspid stenosis, the murmur is in many ways similar to the murmur of mitral stenosis, but it is heard along the lower third of the left edge of the sternum and, like other murmurs from the right heart, increases with inspiration. You can also find a gentle Y-fall in the study of the venous pulse and symptoms of right ventricular failure.
Mesodiastolic noise arises also at other diseases; in all cases, differential diagnosis with mitral stenosis is needed.
With myxoma of the left atrium, there is no click of the opening of the mitral valve and presystolic amplification of the noise. A short, low-frequency murmur at the apex may be caused by increased blood flow through the mitral valve in severe mitral regurgitation, intracardiac shunting, or extracardiac shunting. This noise is low-frequency, it appears after a quiet III tone (which occurs later than the click of the opening of the mitral valve; Fig. 34.1, G). An increase in diastolic blood flow through the tricuspid valve in severe tricuspid insufficiency leads to similar sound phenomena. Flint's murmur is heard in severe aortic insufficiency.
Mesodiastolic noise over the mitral valve occurs not only with stenosis, but also with severe mitral insufficiency, open arterial duct and ventricular septal defect with a large reset, over the tricuspid valve - with severe tricuspid insufficiency and atrial septal defect. This murmur is caused by very high blood flow and usually follows the third tone.
A soft mid-diastolic murmur is sometimes heard in rheumatic attacks (Coombs' murmur), probably due to valvulitis.
In acute severe aortic insufficiency, diastolic pressure in the left ventricle may be higher than in the left atrium, leading to the appearance of a mid-diastolic murmur "diastolic mitral regurgitation".
In chronic severe aortic insufficiency, a mesodiastolic or presystolic murmur (Flint's murmur) often appears. Noise occurs due to the fact that during atrial systole, a counter jet of aortic regurgitation hits the anterior leaflet of the mitral valve and causes it to tremble.
Presystolic murmur
Presystolic murmur occurs during atrial systole, so it only occurs in sinus rhythm. The most common cause is tricuspid stenosis or, less commonly, mitral stenosis. Another reason is myxoma of the right or left atrium. Noise resembles mesodiastolic, but in form it is usually increasing and reaches a peak by the beginning of the loud I tone.
Presystolic murmur occurs against the background of moderate obstruction, in which the transmitral or trans-tricuspid pressure gradient remains small throughout the diastole and increases only in atrial systole.
Heart: systolic-diastolic murmur
Systolic-diastolic noise begins in systole, reaches a maximum to the II tone and continues in diastole, sometimes occupying it all (Fig. 34.1, 3). This noise indicates continuous communication between the chambers of the heart or continuous communication between large vessels in both phases of the cardiac cycle. The noise increases with increasing blood pressure and weakens with inhalation of amyl nitrite. Artificial aortopulmonary or subclavian-pulmonary shunts lead to the appearance of a similar noise.
The causes of systolic-diastolic murmur are listed in Table. 34.1. In two cases, this is a variant of the norm.
With pulmonary hypertension, the diastolic component disappears and the murmur becomes systolic; therefore, with an aortopulmonary septal defect, which is always accompanied by severe pulmonary hypertension, systolic-diastolic murmur is rare.
Noise over the veins of the neck is heard in children and young people in the right supraclavicular fossa and disappears when the internal jugular vein is compressed, its diastolic component is usually louder than the systolic one.
Vascular noise over the mammary glands is caused by an increase in blood flow in them at the end of the third trimester of pregnancy and during lactation; if the membrane of the phonendoscope is pressed harder, the diastolic component disappears.
A classic example of a systolic-diastolic murmur is a patent ductus arteriosus murmur. It is auscultated above or to the left of the pulmonary artery and is sometimes carried out on the back. With a large shunt, pulmonary vascular resistance increases over time, so the diastolic component of the murmur decreases or disappears.
Systolic-diastolic murmur also occurs when an aneurysm of the sinus of Valsalva ruptures (congenital or caused by infective endocarditis). Between the aorta and one of the parts of the heart, often the right atrium or ventricle, a fistula is formed. The pressure gradient on its opposite sides is high both in systole and diastole. The murmur is heard along the right or left side of the sternum and is often accompanied by trembling. Notably, the diastolic component of the murmur is louder than the systolic one.
Systolic-diastolic murmur is sometimes difficult to distinguish from a combination of systolic and diastolic murmurs, for example, with combined aortic valve disease or severe aortic insufficiency; what helps here is that the true systolic-diastolic murmur is not interrupted by the II tone.
There are other causes of systole-diastolic murmur.
With a coronary fistula, sometimes a weak systolic-diastolic murmur with a louder diastolic component is heard at the left edge of the sternum or at the apex.
Systolic-diastolic murmur can also occur with severe stenosis of a large artery. With stenosis of the branches of the pulmonary artery or atresia of the branches of the pulmonary artery and well-developed bronchial collaterals, a systolic-diastolic murmur is heard on the back or in the left axillary region.
Similar noise is also determined in severe coarctation of the aorta; it is characterized by a low delayed pulse in the legs and high blood pressure in the arms, the source of noise is dilated intercostal arteries.
Rubbing noise of the pericardium
A pericardial friction murmur is an intermittent, scraping murmur that may consist of presystolic, systolic, and early diastolic components. If it is heard only in systole, then it can be mistaken for a cardiac or vascular murmur.
The pericardial friction noise increases with full exhalation. It is best heard when the patient is sitting leaning forward.
heard in aortic insufficiency
valve, with pulmonary valve insufficiency, stenosis of the left
atrioventricular orifice, stenosis of the right atrioventricular
openings, with non-closure of the arterial duct, making up the second
half of the systolic-diastolic murmur.
With aortic valve insufficiency, protodiastolic murmur
associated with the reverse flow of blood under high pressure from the vessel to the stomach
daughters (protos - first).
Presystolic murmur is associated with an increase in pressure in the small circle
blood circulation and systole of the hypertrophied left atrium (te-
les - end).
All diastolic murmurs are organic, with the exception of
make only 3 noise.
Flint's noise (A. Flint, 1812-1886, American physician) takes place
with aortic valve insufficiency. With this defect is determined
organic diastolic murmur, in addition, reverse blood flow in the diastolic
tolu lifts the mitral valve leaflet and creates an artificial
mitral stenosis. The valve covers the left atrioventricular
version, narrowing it, and the blood in the diastole of the ventricle comes from the left
atrium into the ventricle through the narrowed opening, resulting in high
the diastolic murmur is suppressed.
Noise of Coombs (C.F.Coombs, 1879-1932b English doctor): at the beginning
attacks of rheumatism, edema of the mitral orifice occurs, which causes
the appearance of diastolic murmur (mesodiastolic murmur of relative
mitral stenosis). As the condition improves, the noise may disappear.
Noise Graham-Still (Graham steell, 1851-1942, English doctor)
characteristic of severe mitral defects, but it is determined above
pulmonary artery, since stagnation in the small circle causes stretching and
expansion of the pulmonary artery, or rather, its mouth, in connection with which there is
relative insufficiency of its valve.
With significant dilatation of the left atrium or left ventricle
relative mitral stenosis occurs, so it is possible that
protodiastolic murmur.
To listen to noises, use the same listening points as
on auscultation of tones. It is necessary to listen to the patient in various
positions: standing, sitting, lying on the back, on the left side, if it allows
the patient's condition, then after physical activity (10 squats),
while holding the breath. The patient should take a deep breath, then exhale
at the same time, blood flow is noticeably accelerated, therefore
conditions for a more distinct appearance or change in the nature of noise.
Murmurs associated with aortic lesions are heard in a standing position,
when the hands are on the back of the head (symptom of Sirotinin-Kukoverov).
Noise is heard better at the site of auscultation of that valve or from
version where it originated. It can be carried out to other areas,
moreover, the noise is better propagated through the blood stream. If the noise is well
peeling off in 2 places, for example, at the apex and at the site of the projection of the aor-
thal hole, and between them and on other holes you can hear much
weaker, this means that there are 2 different noises on two holes
I. In this case, it is sometimes possible to note the difference in the nature of the noise at different times.
ny holes: on one the noise is higher, on the other - lower, there - blowing, there
- scraping.
In addition, you should listen to the entire region of the heart, axillary
depression, interscapular space, vessels.
Let us briefly dwell on the characteristics of noise at the most common
wounded heart defects.
