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Innocent Systolic Murmur Chapter 13. Are G. Talking, MD, FACC Instructor Patricia L. Thomas, MBA, RCIS. Outline. Characteristics of an Innocent Murmur Characteristics of a Pathological Murmur Where Systolic Murmurs May be Produced Classification Still’s Vibratory Systolic Murmur

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Innocent systolic murmur chapter 13 l.jpg

Innocent Systolic MurmurChapter 13

Are G. Talking, MD, FACC

Instructor

Patricia L. Thomas, MBA, RCIS


Outline l.jpg
Outline

  • Characteristics of an Innocent Murmur

  • Characteristics of a Pathological Murmur

  • Where Systolic Murmurs May be Produced

  • Classification

  • Still’s Vibratory Systolic Murmur

  • Physiological Pulmonary Ejection Murmur

  • Supraclavicular Arterial Bruit, Venous Hum

  • Peripheral Pulmonary Stenosis of the Newborn

  • Innocent Aortic Systolic Murmur

  • Mammary Arterial Souffle

  • Straight-Back Syndrome & Pectus Excavatum


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Characteristic of An Innocent Murmur

  • Short (early to mid-systolic, except for the venous hum

  • Low to medium pitch

  • Possibly a musical component

  • Normal physiological splitting of S2

  • Commonly found in children & early teen year

  • Isolated systolic murmurs in the elderly are common & are frequently innocent


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Characteristics of A Pathological Murmur

  • Six Cardinal Clinical Signs

    • Holosystolic Murmur

    • Harsh Murmur

    • Abnormal heart sound

    • Early or mid-systolic click

    • Grade III murmur or greater

    • Heard over the upper left sternal border


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Where Systolic Murmurs May Be Produced

  • Connection of the jugular, subclavian, & innominate veins to SVC (venonus hum; supraclavicular spaces)

  • Connection of RV to MPA (Pulmonary flow murmur; left sternal border, 2nd 3rd intercostal spaces)

  • Connection of the MPA to the RT & LT PA branches (peripheral PS of the newborn; upper sternal border)

  • Connection of the LV to the AO (Still’s murmur; apex)

  • Connection of the Aortic Arch to the brachiocephalic vessels (supra-clavicular arterial bruit; supracalvicular fossa)


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Classification

  • Five types of innocent murmurs heard in childhood:

    • Still’s murmur or vibratory systolic murmur

    • Physiological or functional pulmonary ejection murmur

    • Supraclavicular arterial bruit

    • Venous hum

    • Peripheral Pulmonary stenosis of the newborn


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Still’s Vibratory Systolic Murmur

  • Peak incidence in children 3 to 7 years, disappears at puberty

  • Musical, vibratory, low-frequency, early systolic ejection murmur

  • George F. Stills in 1909

  • “A twanging sound”

  • Turbulence produced by the physiological narrowing of the LV outflow tract

  • Listen with the bell of the stethoscope over the lower mid-precordium or left lower sternal border & across to the apex


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Physiological Pulmonary Ejection Murmur

  • Early systolic, crescendo-decrescendo, mid-frequency, grade II

  • Decreases during inspiration when a child sits

  • Turbulent flow at the origin of the RT & LT pulmonary arteries

  • Listen with the diaphragm of the stethoscope along the left sternal border in the 2nd to 3rd intercostal space in supine position

  • Heard best during inspiration


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Supraclavicular Arterial Bruit

  • Low to medium pitched, short, systolic, crescendo-decrescendo murmur

  • Unaffected by respiration; Grade II or Grade III

  • Heard at any age mid-childhood & in 30% to 40% of young adults

  • Common in high-output conditions; anemia & anxiety; prominent in trained athletes with slow heart rates & high stroke volume

  • Turbulence in the brachiocephalic or carotid arteries at their branching from the aorta

  • Listen with the bell of the stethoscope over the supraclavicular fossa and over the sternomastoid muscle with patient sitting


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Venous Hum

  • Blowing & Continuous extracardiac murmur that is loudest during diastole

  • Whining, roaring, or whirring; intensity varies form faint to grade VI

  • Louder under the inner edge of the right clavicle but extends form the supraclavicular area over the right internal jugular vein to the base of the heart

  • Thrill is often present in children with venous hum

  • Causes result form turbulent blood flow caused by two streams of blood entering the SVC

  • Listen with the bell of the stethoscope in the right supraclavicular space


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Peripheral Pulmonary Stenosis of the Newborn

  • Short mid-systolic ejection murmur of medium pitch & intensity is best heard in the second intercostal space at the left sternal border

  • Result of the turbulence caused when the MPA is bigger or dilated than its branches

  • Heard in newborns and premature infants

  • Listen with the bell of the stethoscope during systole at the upper left sternal border & axillary areas


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Innocent Aortic Systolic Murmur

  • Short, crescendo-decrescendo, low to medium pitch

  • Children, systolic flow murmurs may be secondary to any condition with increased systemic cardiac output

  • Listen with the bell of the stethoscope over the aortic area


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Mammary Arterial Souffle

  • Described by Van Den Bergh in 1908

  • A medium to high-pitched murmur, arising in systole & possibly continuing into diastole

  • Listen with the diaphragm of the stethoscope on the anterior chest wall over the breast


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Straight-Back Syndrome & Pectus Excavatum

  • Decrease of the anteroposterior diameter of the chest because of the loss of the normal degree of kyphosis of the upper thoracic spine, straight-back syndrome or because of the inward cavitation of the sternum at the anterior chest wall

  • Pulmonary systolic ejection murmur

  • Exaggerated inspiratory splitting of S2

  • X-ray revealing displacement of the heart to the left, apparent cardiomegaly, pancake heart


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THE END OF CHAPTER 13

Tilkian, Ara MD Understanding Heart Sounds and Murmurs,

Fourth Edition, W.B. Sunders Company. 2002, pp. 138-153


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