1. DR RAJESH K F

2.  This is a technique of altering circulatory dynamics by means of a variety of physiological and pharmacological maneuvers and determining their effects on heart sounds and murmurs

3. Interventions most commonly employed are  Respiration  Postural changes  Isometric exercise  Valsalva maneuver  Premature ventricular contractions  Vasoactive agents- amyl nitrite,methoxamine,phenylephrine

4. Splitting of S2

5. Heart sounds Accentuated during Inspiration  RVS3 and RVS4  Tricuspid OS Expiration  LVS3 and LVS4  mitral OS

6. Pulmonary ejection click  Inspiration diminish intensity of valvular PEC  PA diastolic pressure is very low  Inspiration causes elevation of RV EDP  RV late diastolic Pr > PA Pressure  Causes partial presystolic opening of PV  Less upward motion of valve during systole

8. MURMURS  Respiration exerts more pronounced and consistent alterations on murmurs of right side than left side  Especially tricuspid murmurs 100% sensitivity, 88% specificity  Inspiration increases venous return to right side of heart  Expiration increases venous return to left side of heart

9. Inspiration  TS  TR (Carvallo’s sign)  PR  Mild or moderate PS  Severe PS no further increase in gradient Expiration  MS  MR  AS  AR  VSD  Pericardial rub (AP diameter)

10. MVP  MSC and systolic murmur occur earlier during systole in inspiration  Inspiratory reduction in LV size  Increased redundancy of MV  Increase valvular prolapse

12.  Effects of inspiration on auscultatory findings may be accentuated by Muller maneuver  Converse of Valsalva Maneuver  Forced inspiration against closed glottis  Forcibly inspires while the nose is held closed and mouth is firmly sealed for about 10 sec.

13.  Widens split S2 and augments murmur and filling sound originating in right side of the heart.

14. RAPID STANDING  Decrease in venous return, thus stroke volume

15.  Width of the splitting become reduced  No change in patients with true fixed split Decrease in intensity  RVS3 and RVS4  LVS3 and LVS4

16. Decrease in intensity  Semilunar valve stenosis  AV valve regurgitation murmurs  VSD  Most functional systolic murmurs

17.  Since LV EDV is decreased Increase in murmurs  HOCM(95% sensitivity, 84% specificity)  Early MSC and murmur of MVP

18. SQUATTING  Sudden change from standing to squatting position  Increase venous return and systemic resistance simultaneously  Squatting abruptly increases ventricular preload and afterload  Arterial pressure rise may cause transient reflex bradycardia

19. Increase in stroke volume causes augmentation of  S3 and S4(of both ventricles)  Right sided murmurs  MS  AS

20. Elevation of arterial pressure  Increase in aortic reflux AR  Increase in MR volume  Increase in LT to RT shunt in VSD  Increase in blood flow through RVOT in TOF

21. Combination of elevated arterial pressure and venous return  Increase LV size and reduce LVOT obstruction  Decrease murmur in HOCM(95% sensitivity, 85% specificity)  Click and murmur of MVP delayed

23. LEFT LATERAL RECUMBENT POSITION Accentuate intensity of  S1  LVS3 and LVS4  OS of MS  Murmurs of MS and MR  Click and murmur of MVP  Austin Flint murmur

24. SITTING AND LEANING FORWARD  Accentuate AR and PR murmur (mechanical)

25.  This can be carried out by using a calibrated handgrip device or a handball  Better to carryout bilaterally  Should be sustained for 20 to 30 secs  Valsalva maneuver during the handgrip must be avoided  Contraindicated in patients with myocardial ischemia and ventricular arrhythmias

26. Isometric exercise results in significant increase in  Systemic vascular resistance  Arterial pressure  Heart rate  COP  LV filling pressure  Heart size

27.  Systolic murmur of AS diminished –reduction of pressure gradient across AV  Diastolic murmur of AR and systolic murmurs of rheumatic MR and VSD increases  LVS3 and LVS4 accentuated  Diastolic murmur MS becomes louder – increase in flow across valve

28. Increase LV volume  Systolic murmur of HOCM decreased  Click and murmur of MVP delayed

29.  Forced expiration against a closed glottis Standard test consists of asking the patient to blow against an aneroid manometer and maintain a pressure of 40mmhg for 30seconds

30.  Relatively deep inspiration followed by forced exhalation against a closed glottis for 10 to 20 seconds  Physician has to keep flat of the hand on the abdomen to provide the patient a force to breathe against  Normal response has four phases

31. PHASE1  Intrathoracic pressure rises  Transient increase in LV output and SBP

32. PHASE II STRAINING PHASE  Systemic venous return decrease  Filling of right and then left side reduced  Stroke volume reduced  Mean arterial and pulse pressures falls  Reflex tachycardia

33.  A2-P2 interval narrows Attenuation of  S3 and S4  AS & PS  MR & TR  AR & PR  TS & MS

34. Since LV volume is reduced  Murmur of HOCM increased(65% sensitivity, 95% specificity)  Systolic click and murmur of MVP commence earlier

35. PHASEIII VALSALVA RELEASE  During first two cycles following release murmurs and sounds(S3 and S4) right side of heart return to normal  After six to eight cycles sounds and murmurs originating from left side of heart returns to normal  A2-P2 split increases  Decrease SBP

36.  PHASE IV OVERSHOOT PHASE  Murmurs and heart sounds transiently augmented

39. Followed by a significant pause  Increase in ventricular filling  Augmentation of cardiac contractility- post extra systolic potentiation

40. During postpremature beat – augmented are  ESM of AS and PS ^volume ^contractility  HOCM ^contractility-increase dynamic LVOT obstruction ^volume-decrease LVOT obstruction net increase gradient

41.  PSM of MR and of VSD - not altered(relatively little further increase in mitral valve flow or change in the LV-LA gradient) (ventricle has has 2 openings aorta and LA in MR not in AS)  Systolic murmur of papillary muscle dysfunction diminish  Increase in LV size delays systolic click and murmur of MVP (depend mainly on volume)

44.  Similar auscultatory changes follow prolonged diastolic pauses in AF

45. AMYL NITRITE INHALATION  Crush ampoule in towel  take 3-4 deep breaths over 10 – 15 secs  First 30 secs– Systemic art pressure decrease  30 to 60 secs– Reflex Tachycardia  > 60 secs -CO,HR and Velocity of BF increase

46.  S1 augmented  A2 diminished  OS mitral and tricuspid valve become louder  A2 OS interval shortens  RVS3 and LVS3 augmented –rapidity of ventricular filling  LVS3 associated with MR diminished(MR reduced)

47. Systolic murmurs accentuated are  HOCM  AS  PS  TR  Functional systolic murmurs Increased ventricular contractility and SV

48. Due fall in systemic arterial pressure murmurs diminished are  PSM of MR  PSM of VSD  EDM of AR  Austin flint murmur  Continuous murmur of PDA  Continuous murmur of AVF

49. Systolic ejection murmur of TOF diminished  Decrease in arterial pressure  Increase right to left shunt  Decrease blood flow in RVOT

50. Reduction cardiac size leads to  Early appearance of click and murmur of MVP  Murmur intensity show variable response

51. Amyl nitrate response useful in distinguishing  Systolic murmur of AS(^)and MR(v)  Systolic murmur of TR(^) and MR(v)  Systolic murmur of PS(^) and TOF(v)  Systolic murmur of PS(^) and VSD(v)  Diastolic murmur of MS(^) and Austin flint(v)  EDM of PR(^) and AR(v)

52. METHOXAMINE AND PHENYL EPHRINE  Increase systemic arterial pressure  Reflex bradycardia and decreased contractility and COP  Contraindicated in CHF and HTN

53.  Methoxamine 3-5 mg IV increase arterial pressure by 20-40 mm Hg for 10 to 20 min  Phenylephrine 0.5mg IV elevates systolic pressure around 30mm Hg for 3-5min  Phenylephrine preferred due to shorter duration action

54.  S1 reduced  A2 becomes louder  A2 OS prolonged  S3 and S4 response variable

55. Increase in arterial pressures cause following murmurs louder  EDM of AR  PSM of MR  VSD  TOF  Continuous murmurs of PDA and AVF

56.  Systolic murmur of HOCM softens(^ LV size)  Click and murmur of MVP delayed(^ LV size) Decrease in COP diminish  ESM of AS  Functional systolic murmurs  MDM of MS

57. TRANSIENT ARTERIAL OCCLUSION  Transient external compression of both brachial arteries  By bilateral cuff inflation to 20 mm Hg greater than peak systolic pressure  Augments the murmurs of MR, VSD, and AR

58. Inspiration, Sudden standing Dec pulmonary venous return, Reduces LAP  MDM reduced  OS softens  A2-OS gap widen  Three sequential sounds (A2, P2, and OS) may be audible Exercise,Squatting,Amyl Nitrate  MDM accentuated

59.  Varies little with respiration Decrease murmur  Sudden standing  Valsalva  Amyl Nitrate Augments the murmur  Squatting  Isometric Exercise

60. Murmur increases on  Post PVC beat  squatting Reduces AS murmur  Valsalva  Standing  handgrip

61. EDM increases on  sitting up and leaning forward  Squatting  Isometric exercise  Vasopressors Decreases with  Amyl Nitrate  Valsalva

62. Murmur and click earlier(intensity decreases) LV Volume decrease  Standing  Valsalva Murmur and click later LV Volume increase  Squatting  Post ectopic  Isometric Exercise (intensity increases)

64. Increase murmur in  Valsalva  Standing  Post ectopic Decrease murmur in  Sustained Handgrip  squatting  Methoxamine

65.  AS X HOCM squatting (^/v) valsalva/standing (v/^)  AS x MR handgrip (v/^) phenyl ephrine (v/^) post pvc (^/v) amyl nitrate (^/v)

67.  MS X TS respiration  MR X TR respiration  MS X AUSTIN FLINT amyl nitrate(^/v)  PS X AS respiration  PS X Small VSD amyl nitrate (^/v) phynylephrine (v/^) respiration  PR X AR squatting (_/^) sus handgrip (-/^)

68.  THANK U

70. 1. During phase 2 of valsalva A2-P2 interval A. Increase B. Decrease C. No change D. Any of the above

71. 2.Intensity of murmur in MVP during isometric handgrip A. Increase B. Decrease C. No change D. Increase then decrease

72. 3. Rheumatic MR murmur increase with all the following except A. Sudden squatting B. Isometric handgrip C. Phenyl ephrine D. Amyl nitrate

73. 4. After amyl nitrate systolic murmur of VSD A. Increase B. Decrease C. No change D. Any of the above

74. 5.After squatting AS murmur A. Increase B. Decrease C. No change D. Increase then decrease

75. 6. PS murmur following handgrip A. Increase B. Decrease C. No change D. Increase then decrease

76. 7.HOCM murmur increase following post ectopic beat due to A. Increase LV volume B. Contractility C. Decrease LV volume D. Decrease gradient

77. 8. A2 OS gap during standing A. Increase B. Decrease C. No change D. Increase then decrease

78. 9.Amyl nitrate is A. liquid silver B. Venodilator C. Arterial dilator D. both

79. 10. MDM of MS increase in A. Left lateral position B. Coughing C. Handgrip D. All the above

80. 1. During phase 2 of valsalva A2-P2 interval A. Increase B. Decrease C. No change D. Any of the above

81. 2.Intensity of murmur in MVP during isometric handgrip A. Increase B. Decrease C. No change D. Increase then decrease

82. 3. Rheumatic MR murmur increase with all the following except A. Sudden squatting B. Isometric handgrip C. Phenyl ephrine D. Amyl nitrate

83. 4. After amyl nitrate systolic murmur of VSD A. Increase B. Decrease C. No change D. Any of the above

84. 5.After squatting AS murmur A. Increase B. Decrease C. No change D. Increase then decrease

85. 6. PS murmur following amyl nitrate A. Increase B. Decrease C. No change D. Increase then decrease

86. 7.HOCM murmur increase following post ectopic beat due to A. Increase LV volume B. Contractility C. Decrease LV volume D. Decrease gradient

87. 8. A2 OS gap during standing A. Increase B. Decrease C. No change D. Increase then decrease

88. 9.Amyl nitrate is A. liquid silver B. Venodilator C. Arterial dilator D. both

89. 10. MDM of MS increase in A. Left lateral position B. Coughing C. Handgrip D. All the above