1. Dr. R. Tandon Sitaram Bhartia Institute, New Delhi

2. Continuous Murmurs Defn. :- A murmur starting in systole and going through the S2 in diastole. A murmur starting in systole and going through the S2 in diastole. A murmur present throughout the cardiac cycle : covers S1, S2 whole of systole and diastole, may be louder in systole or diastole. A murmur present throughout the cardiac cycle : covers S1, S2 whole of systole and diastole, may be louder in systole or diastole.

3. Continuous Murmurs To & fro murmur :- A gap between the systolic and diastolic murmurs identifies two separate murmurs.

4. Continuous Murmurs Clinical Setting :- Cyanotic or acyanotic. Cyanotic or acyanotic. Features of aortic run off Features of aortic run off - present, absent. Features of hyperkinetic circ. Features of hyperkinetic circ. - present, absent. Cardiac chambers involved Cardiac chambers involved - all or partial.

5. Continuous Murmurs Acyanotic patients :- PDA PDA S. of Valsalva-RA/RV fistula S. of Valsalva-RA/RV fistula Coron. AV fistula Coron. AV fistula Systemic AV fistula. Systemic AV fistula. Coarctation of the aorta Coarctation of the aorta Peripheral PS. Peripheral PS. Anom. LCA from PA. Anom. LCA from PA. AP window. AP window. MS with small ASD. MS with small ASD. Venous hum. Venous hum. Post traumatic. Post traumatic.

6. Continuous Murmurs Cyanotic patients :- Bronchial collat. in TOF physiology Bronchial collat. in TOF physiology PDA in TOF physiology PDA in TOF physiology TAPVC TAPVC Pulm. AV fistula Pulm. AV fistula PTA PTA Surgical shunts Surgical shunts

7. Continuous Murmurs T.O.F. Physiology :- Fallot’s tetralogy Fallot’s tetralogy Tricuspid atresia Tricuspid atresia DORV with VSD & PS/PA DORV with VSD & PS/PA TGA with VSD & PS/PA TGA with VSD & PS/PA Single vent. With PS / PA Single vent. With PS / PA Miscellaneous malpositions with VSD & PS/PA. Miscellaneous malpositions with VSD & PS/PA.

8. Continuous Murmurs PDA :- Max intensity ULSB. Thrill ± Max intensity ULSB. Thrill ± Systolic component louder, harsh broken into multiple clicks. Systolic component louder, harsh broken into multiple clicks. Diastolic component smooth and decrescendo. Diastolic component smooth and decrescendo. Hollow character Hollow character Peaks at S2. Peaks at S2. With PAH the diastolic component becomes shorter and may disappear. With PAH the diastolic component becomes shorter and may disappear. May be palpable as systolic or cont. thrill. May be palpable as systolic or cont. thrill.

9. S1S2S1 CM x

10. Continuous Murmurs Sinus of Valsalva fistula :- Palpable as cont. thrill. Palpable as cont. thrill. Loud grade V / VI. Loud grade V / VI. May mask both S1 and S2 May mask both S1 and S2 Louder systolic component if VSD is present. Louder systolic component if VSD is present. Louder diastolic component if AR is present. Louder diastolic component if AR is present. Both VSD and AR may be present. Both VSD and AR may be present.

11. Continuous Murmurs Sinus of Valsalva fistula :- Louder at RSB if in RA. Louder at RSB if in RA. Louder at MLSB if in RV. Louder at MLSB if in RV. Systolic component may be softer.

12. S1S2S1 CM

13. Continuous Murmurs Coron. AV fistulae :- Relatively uncommon. Relatively uncommon. CM – 2 to 6 in intensity. CM – 2 to 6 in intensity. Mid to lower L, RSB. Mid to lower L, RSB. Shunt size usually small. Shunt size usually small. Myocard. isch. uncommon Myocard. isch. uncommon

14. Continuous Murmurs Syst. AV fistulae :- Intra cranial, intrahepatic, chest wall, abdomen, extremities. Intra cranial, intrahepatic, chest wall, abdomen, extremities. CM. grade 2 to 4, midsystolic and diastolic peaks. CM. grade 2 to 4, midsystolic and diastolic peaks. Depending on size of shunt; features of (a) aortic runoff (b) hyperkinetic circ state (c)  syst. ven. pr. (d) CCF specially neonates. Depending on size of shunt; features of (a) aortic runoff (b) hyperkinetic circ state (c)  syst. ven. pr. (d) CCF specially neonates.

15. Continuous Murmurs Coarctation of the Ao :- Systolic hypertension arms. Systolic hypertension arms. Systolic pr. diff between upper and lower segment – ejection syst. m. Systolic pr. diff between upper and lower segment – ejection syst. m. Identical diast. pr. – no diast. m. Identical diast. pr. – no diast. m. Cont. murmurs rare. Cont. murmurs rare.

17. Continuous Murmurs Peripheral PS :- Systolic gradient between proximal and distal segments – ejection syst. m. Systolic gradient between proximal and distal segments – ejection syst. m. No diastolic gradient No diastolic gradient - no diastol. or CM. Rarely a diastolic gradient may be present & CM. Rarely a diastolic gradient may be present & CM. Acyanotic; PAH ± Acyanotic; PAH ±

19. Continuous Murmurs ALCAPA :- High PA pr. perfuses LCA at birth. High PA pr. perfuses LCA at birth. ↓ PVR by 3-6 wks - myocard. ischaemia - anterolat. M.I. ↓ PVR by 3-6 wks - myocard. ischaemia - anterolat. M.I. Rarely good collaterals from RCA to LCA. Rarely good collaterals from RCA to LCA. - Present in childhood or later as a CM with small L to R shunt. small L to R shunt. Dx. : Echo; RCA angio. Dx. : Echo; RCA angio.

20. Continuous Murmurs AP Window :- Relatively rare anomaly. Relatively rare anomaly. Usually large defects hence no CM. Usually large defects hence no CM. 1-2% small. Atypical loud CM at 2 or 3 LICS. 1-2% small. Atypical loud CM at 2 or 3 LICS. Dx. Difficult. Site of m. unusual for PDA. Dx. Difficult. Site of m. unusual for PDA.

21. Continuous Murmurs MS with small ASD :- Findings of MS. Findings of MS. Loud venous hum at ¾ RSB. Loud venous hum at ¾ RSB. Louder in systole and expiration. Louder in systole and expiration. ? Is frequency higher. ? Is frequency higher.

22. Continuous Murmurs Venous hum :- Common upto 6 to 8 yrs. Common upto 6 to 8 yrs. RSB, above clavicle, child sitting up. RSB, above clavicle, child sitting up. Intensity  with inspiration. Intensity  with inspiration. May disappear : head to left, pressure above clavicle, lying down. May disappear : head to left, pressure above clavicle, lying down.

23. Continuous Murmurs TOF Physiology : Severe obstr. Or PA. Severe obstr. Or PA. Bronchial or Aorto pulm. collaterals perfuse PA. Bronchial or Aorto pulm. collaterals perfuse PA. Soft venous hum like CM. Soft venous hum like CM. - Chest wall, interscapular area. Large flow – louder m. Large flow – louder m. - Mild cyanosis, LVE, Ao. runoff ±. If PDA – usual site, m. can be atypical. If PDA – usual site, m. can be atypical.

24. Continuous Murmurs TAPVC :- CM : SSN, upper RSB,  flow, no obstr. CM : SSN, upper RSB,  flow, no obstr. Infradiaphragmatic : CM in epigastrium, over the liver. Infradiaphragmatic : CM in epigastrium, over the liver. Obstr. site of PV entry to syst. V. / RA. Obstr. site of PV entry to syst. V. / RA. Features of severe PAH less common with CM. Features of severe PAH less common with CM.

25. Continuous Murmurs Pulm. AVF :- Unexplained cyanosis. Unexplained cyanosis. Hemoptysis, embolism, brain abscess. Hemoptysis, embolism, brain abscess. No CE, S1 & S2 normal, no m. No CE, S1 & S2 normal, no m. ECG normal. ECG normal. Cont. m. over chest wall. Cont. m. over chest wall. Chest x-ray may identify. Chest x-ray may identify. Contrast : left brachial inj. Contrast : left brachial inj.

27. Continuous Murmurs Persistent truncus :- Ejection syst. m. ends before A2. Ejection syst. m. ends before A2. Truncal regurg. m. starts with A2. Truncal regurg. m. starts with A2. Usually to & fro m. Usually to & fro m. Rarely PA osteal stenosis may result in CM. Rarely PA osteal stenosis may result in CM. Dx. : Echo Doppler Dx. : Echo Doppler

28. Continuous Murmurs VSD with AR :- Pansyst. m masks S1 and S2. Pansyst. m masks S1 and S2. AR m. starts with A2. AR m. starts with A2. No gap at upper LSB. No gap at upper LSB. Below Lt. clavicle m. character → to and fro. Below Lt. clavicle m. character → to and fro.

29. Continuous Murmurs AS with AR :- to & fro. m. AS m. ends before A2. AS m. ends before A2. AR m starts from A2. AR m starts from A2. Gap easily appreciable should not be mistaken for a CM. Gap easily appreciable should not be mistaken for a CM.

30. S1S2S1 X ESMARM

31. Continuous Murmurs Acyanotic patients : Physiol. effects L → R shunt L → R shunt Vol overload of circ. Vol overload of circ. Hyperkinetic circ. State ↓ SVR,  CO, Hyperkinetic circ. State ↓ SVR,  CO,  HR and SV  HR and SV  Plasma vol.  Plasma vol. Aortic runoff. Aortic runoff.

32. Continuous Murmurs Acyanotic patients : Physiol. effects  syst. ven. pr.  syst. ven. pr.  M VO 2.  M VO 2.  Ao diast. Pr.Myocard.  Ao diast. Pr.Myocard.  LV edp.Ischaemia  LV edp.Ischaemia  diast. Filling time  diast. Filling time

33. Continuous Murmurs Cyanotic patients : Physiol. effects Depend on anomaly Depend on anomaly Pulm. AVF Pulm. AVF -  PVR in fistula -  PVR non affected area - R → L shunt – cyanosis - Potential for paradox embolism, brain abscess, hemoptysis.

35. S1S2S1 X ESM ARM CM