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”
Dynamic 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
Maneuvres PHYSI(OLOGI)CAL• Postural change Supine / L Lateral Standing Squatting• Valsalva• Handgrip• Cycle length change
PHARMACOLOGICAL• Amyl nitrite• Phenylephrine
Position
• 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
Respiration• 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
Carvallo’s sign• Inspiratory accentuation of TR murmur• Early systolic murmur > holosystolic• Blowing quality > musical• Absent in severe RV failure associated TS is severe• If venous pressure is very high,
listening in upright posture may help
Reversed Carvallo sign HCM with RVO obstruction - ? ↑ VR > widened RVO
Respiration• 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
Pms = mean systemic pressure; Ppc = pulmonary capillary hydrostatic pressure; Ppi = pulmonary interstitial hydrostatic pressure; Ptm = pulmonary capillary transmural pressure
Abrupt 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
Isometric Hand Grip
HAND DYNAMOMETER
Physiological changes of
ISOMETRIC HANDGRIP EXERCISE
Isometric Hand Grip
LV S3 & S4 get augmentedMurmurs of MR,AR,VSD intensifyMitral stenotic murmur may augmentSystolic murmur of HOCM may diminishClick & late sytolic murmur of MVP get delayed
Transient Arterial Occlusion
Squatting• Increased venous return and CO >
augments most murmurs atleast initially (AS,PS,MR,AR,VSD) Right heart murmurs do so earlier
• Increased ventricular volume > murmur of HOCM ↓ murmur of MVP ↓→
• Ejection murmur of TOF ↑
P Hanson Br HeartJ7 1995;74:154
Central Aortic Pressure
T Murakami AHJ 2002; 15:986–988
Hemodynamics of Squatting T Murakami AHJ 2002; 15:986–988
T Murakami AHJ 2002; 15:986–988
Valsalva Maneuver
Decreased venous return & CO, HR ↑; PP↓ S2 split narrows down, S3 & S4 diminish
Valsalva 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
VALSALVA STRAIN
ASD, HF, MS
Cycle 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
Aortic Stenosis HOCM
Amylnitrite 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
Amyl Nitrite Inhalation
Augments Diminishes• Aortic stenosis Mitral regurgitation• Pulmonary stenosis TOF• Tricuspid regurgitation Mitral regurgitation• Mitral stenosis Austin Flint• Pulmonary regurgitation Aortic Regurgitaation
Phenylephrine↑ 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
↑Afterload,↑Preload,↓Contractility
↓Afterload,↓Preload,↑Contractility
Valslava
the 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
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