Dynamic Ausculatation

Report
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
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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
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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 augmented
Murmurs of MR,AR,VSD intensify
Mitral stenotic murmur may augment
Systolic murmur of HOCM may diminish
Click & 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 Variation
Post 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
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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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