Etiology and Diagnosis of Systolic Murmurs in Adults Steven McGee, MD  The American Journal of Medicine  Volume 123, Issue 10, Pages 913-921.e1 (October 2010) DOI: 10.1016/j.amjmed.2010.04.027 Copyright © 2010 Terms and Conditions

Figure 1 The 6 murmur patterns are distinguished by their distribution with respect to a key landmark, the 3rd left parasternal interspace (indicated by “+” on each drawing). Two patterns (broad apical-base pattern and small apical-base pattern, top 2 rows) extend above and below this landmark, usually to both sides of the sternum. The “broad apical-base” pattern extends at least from the first right parasternal space to the apex (ie, 4th intercostal space at the midclavicular line [MCL]), whereas the “small apical base” pattern does not extend this far. Three patterns are confined entirely below this landmark (left lower sternal pattern, broad apical pattern, and isolated apical pattern, 3rdthrough 5throws); 1 pattern is confined entirely above this landmark (isolated base pattern, bottom row). The vertical line over the left chest in each drawing depicts the MCL. The American Journal of Medicine 2010 123, 913-921.e1DOI: (10.1016/j.amjmed.2010.04.027) Copyright © 2010 Terms and Conditions

Figure 2 Murmur patterns of isolated lesions. The figure presents the murmur patterns reflecting isolated aortic velocity (top row; 247 patients without significant mitral or tricuspid regurgitation), isolated mitral regurgitation (middle row; 174 patients with AV peak velocity <1.8 m/sec and without significant tricuspid regurgitation), and isolated tricuspid regurgitation (bottom row; 161 patients with AV velocity <1.8 m/sec and without significant mitral regurgitation). See text. The American Journal of Medicine 2010 123, 913-921.e1DOI: (10.1016/j.amjmed.2010.04.027) Copyright © 2010 Terms and Conditions

Figure 3 Boundary of murmur patterns. The 3rd left parasternal space overlies both the aortic and mitral valves. If the ventricles vibrate sufficiently to produce sound, murmurs are generated below this landmark. Vibrations of the right ventricle produce the “left lower sternal” pattern, whereas those of the left ventricle produce the “isolated apical” pattern, larger apical patterns (left example of “broad apical” pattern, Figure 1) or, if of sufficient intensity, murmurs along the left ribs from sternum to axilla (right example of “broad apical” pattern, Figure 1). Should the great arteries vibrate sufficiently to make sound, the bones above this landmark vibrate and murmurs radiate from the upper sternum to clavicles and neck (“isolated base” pattern). With increased velocity across the aortic valve, both the left ventricle (lower ribs) and great arteries (upper sternum and clavicles) vibrate, causing the “apical-base pattern” and its variations. The American Journal of Medicine 2010 123, 913-921.e1DOI: (10.1016/j.amjmed.2010.04.027) Copyright © 2010 Terms and Conditions