1. Regurgitant Systolic Murmurs Chapter 15
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS

2. Outline Mitral Regurgitation Tricuspid Regurgitation
Ventricular Septal Defect
Patent Ductus Arterious
Acute Ventricular Septal Perforation
Papillary Muscle Rupture
Mitral Valve Prolapse Syndrome

3. Introduction
Regurgitant Murmurs are caused by retrograde flow across AV valves
TR heard at the lower left sternal border
MR heard at the apex
Holosystolic Murmurs suggest MR, TR, VSD’s

4. Chronic Mitral Regurgitation
Continues as long as LV pressure > that of the enlarged LA
Begins at S1 and extend through S2
Large high pitched, blowing holosystolic/pansystolic murmur

5. Acute Mitral Regurgitation
Loud Grade IV or >, diamond shaped
Pressure in the normal nondilated LA increases rapidly because of regurgitant flow in early systole and = LV pressure in late systole

6. Mitral Regurgitation Causes
Rheumatic Heart Disease
Papillary Muscle Dysfunction
Mitral Valve Prolapse
Rupture Chordae Tendineae
Calcified mitral Annulus
LV Dilatation

10. Tricuspid Regurgitation
The holosystolic murmur of MR engulfs A2 but stops before P2 whereas the murmur of TR persists through and engulfs P2
Increases with inspiration (Carvallo sign) & does not radiate well to the axillary region

11. Mild TR
Infective Endocarditis seen with IV drug abuse may be mid-systolic of low intensity, heart only with inspiration
S4 may be present
Advance TR
May not increase with inspiration or may be absent
Tricuspid honk or whoop (highly musical)

12. Causes
Tricuspid Insufficiency is commonly secondary to dilatation of the right ventricle
Severe Right Heart Failure secondary to mitral stenosis
Pulmonary Heart Disease with pulmonary hypertension
Congenital deformity (Epstein's Anomaly), Rheumatic Valve disease, or Infective Endocarditis
Listen with the diaphragm of the stethoscope along the lower left sternal border (third interspace)

13. Ventricular Septal Defect
Holosystolic, loud, & harsh; S2 is loud & widely split; possible palpable thrill
Begins with ventricular systole S1, when the rise in LV pressure exceeds that of the RV & continues until S2 when left ventricular pressure falls
Listen with the diaphragm of the stethoscope from the mid-to lower left sternal border

15. Patent Ductus Arteriosus Acute Ventricular Septal Perforation
Continuous murmur
Acute Ventricular Septal Perforation
Caused by acute MI
Loud short systolic murmur, grade IV
Listen with diaphragm of stethoscope
Papillary Muscle Rupture
mid-to late systolic murmur, thrill
Listen with diaphragm for the stethoscope

16. Mitral Valve Prolapse Syndrome
Mid-to-late systolic, late systolic, or holosystolic
Moderate Prolapse
1/3 or ½ into systole & increases its intensity until A2
Valve is competent in early systole & prolapse in LA in late systole
Severe Prolapse
Loud S1, holosystolic murmur
Fusion of a click with S1, Sound is louder
Click
In < ½ of patients marks onset of the murmur “click murmur syndrome”
Cause
Mitral insufficiency

18. THE END OF CHAPTER 15
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp