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MURMUR AND ANAESTHESIA. DR BALAJI ASEGAONKAR CONSULTANT CARDIAC-ANAESTHESIOLOGIST , OZONE ANAESTHESIA GROUP, AURANGABAD . The Case. 22 yr M, suffered RT accident –suspected closed vascular injury No cardiac or pulmonary history No prior cardiac workup

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murmur and anaesthesia







The Case

  • 22 yr M, suffered RT accident –suspected closedvascular injury
  • No cardiac or pulmonary history
  • No prior cardiac workup
  • EKG normal, labs normal
  • II/VI mid systolic crescendo- murmur
  • Pre op 2D Echo advised.
  • But…………….Not possible.
Able to swim and walks for hours without dyspnoea or chest pain.
  • No thrill on murmur.
  • ECG and CxR normal
aim of presentation
  • Do all murmurs requires further investigation?
  • On auscultation if someone finds murmur- What should be done?
  • Which murmurs are significant ?
  • Is the murmur is physiological or pathological?
so what do you do
So what do you do?
  • Guess?…Argue?…Worry?…Refer everyone to cardiology?
  • Or do a thorough, focused exam.
  • …for evaluation, risk stratification, and management…
  • …and refer, delay, or cancel only when appropriate.
what do you mean thorough focused exam
What do you mean, thorough, focused Exam:
  • We are not cardiologists: We simply need to recognize when a cardiac condition affect the patient’s response to anaesthesia, and what to do about it.
  • Thorough enough to find all significant problems (sensitivity).
  • Focused enough to consider only significant problems (specificity).
and stepwise approach
....and StepwiseApproach?
  • Thorough, focused cardiac evaluation
  • Indicated cardiac testing and consultation.
  • Optimization of cardiovascular function in relation to the demands of the surgery and the anaesthesia.
  • Dyspnoea on exertion
  • Orthopnea,PND.
  • Palpitations.
  • Easy fatigability
  • Syncope.
  • Chest pain.
  • Others.
clinical examination
Clinical examination
  • Pulse
  • Blood pressure
  • Baseline saturation
  • Respiration
  • Anaemia
  • Signs of failure
  • Systemic examination
clinical examination1
Clinical examination
  • Inspection
  • Palpation – Thrill,2 nd HS
  • Auscultation
how to listen
How to listen
  • Do a good exam
    • left lateral decub
    • touch skin, listen
    • quiet
    • good ear fit
    • correct stethoscope placement
    • use maneuvers
maneuvers to differentiate murmurs
Maneuvers to Differentiate Murmurs
  • Valsalva: All murmurs decrease n intensity except HOCM & MVP – longer and louder
  • Respiration: Right sided sounds and murmurs get louder with inspiration
  • Prompt Squatting : increase VR and SVR -murmur of HOCM gets softer, The murmurs of MR& AR get louder.
classification of murmurs
Classification of Murmurs
  • Timing
    • The relative position within the cardiac cycle and relation to S1/S2.
  • Intensity
    • Grade 1: Heard only with intense concentration
    • Grade 2: Faint, but heard immediately
    • Grade 3: Easily heard, of intermediate intensity
    • Grade 4: Easily heard and associated with a thrill
    • Grade 5: Very loud, with thrill and audible with only edge of stethoscope on chest wall
    • Grade 6: Audible with stethoscope off the chest wall
innocent murmur
Innocent murmur
  • Short systolic ejection murmur
  • Loudest at left sternal border
  • Grade 1-2/6
  • Normal S2
  • No other exam abnormalities
  • No evidence LVH or dilatation
  • No thrill
  • No increase with Valsalva
pathological murmurs
Pathological murmurs
  • Diastolic { MS,AR}
  • Harsh murmurs
  • Associated with thrill.
  • Abnormal S1 or S2
  • Louder than 3/6
  • ECG & CxR changes.
  • Other clinical findings.
common murmurs and timing click on murmur to play
Common Murmurs and Timing (click on murmur to play)

Systolic Murmurs

  • Aortic stenosis
  • Mitral insufficiency
  • Mitral valve prolapse
  • Tricuspid insufficiency

Diastolic Murmurs

  • Aortic insufficiency
  • Mitral stenosis

S1 S2 S1

severe stenotic lesions
Severe stenotic lesions
  • History- angina , syncope, CCF
  • Narrow pulse pressure.
  • ECG changes.
  • Chest X ray :Cardiomegaly ,post stenotic dilated aorta
  • Murmur with thrill
severe regurgitant lesions
Severe regurgitant lesions
  • Symptomatic patients
  • Wide pulse pressure.
  • Other signs of WPP.
  • Presence of ccf.
  • Cardiomegaly on X ray.
if i miss murmur what will happen
If I miss murmur,what will happen ?
  • Nothing…..
  • Nonsymptomatic Pt + murmur =mild lesion
  • Symptomatic Pt + murmur = Dangerous

For a link to sound files demonstrating examples of the heart sounds and murmurs in this presentation go to


How is a paradigm



A group of scientists placed 5 monkeys in a cage and in the middle, a ladder with bananas on the top.


Every time a monkey went up the ladder, the scientists soaked the rest of the monkeys with cold water.


After a while, every time a monkey went up the ladder, the others beat up the one on the ladder.


After some time, no monkey dare to go up the ladder regardless of the temptation.


Scientists then decided to substitute one of the monkeys. The 1st thing this new monkey did was to go up the ladder. Immediately the other monkeys beat him up.

After several beatings, the new member learned not to climb the ladder even though never knew why.


A 2nd monkey was substituted and the same occurred. The 1st monkey participated on the beating for the 2nd monkey. A 3rd monkey was changed and the same was repeated (beating). The 4th was substituted and the beating was repeated and finally the 5th monkey was replaced.


What was left was a group of 5 monkeys that even though never received a cold shower, continued to beat up any monkey who attempted to climb the ladder.


If it was possible to ask the monkeys why they would beat up all those who attempted to go up the ladder…..

I bet you the answer would be….

“I don’t know – that’s how things are done around here”

Does it sounds familiar?


Don’t miss the opportunity to share this with others as they might be asking themselves why we continue to do what we are doing if there is a different way out there.

aortic stenosis
Aortic stenosis
  • Many studies tried to come up with grading systems. Valid factors (to one degree or another) included:
    • Decreased carotid volume
    • Delayed carotid upstroke
    • Decreased or absent S2
    • Murmur loudest at RUSB
    • Valve calcification on CXR
  • Anesthesiologists also look for wide aorta on CXR from post-stenotic dilation
  • Look for:
    • effort syncope
    • angina
    • dyspnea
    • slow carotid rise
    • murmur peak in mid or late systole
    • decreased or absent S2
    • pulse delay,
  • Trust the innocent murmur
    • Short systolic ejection murmur
    • Loudest at left sternal border
    • Grade 1-2/6
    • Normal S2
    • No other exam abnormalities
    • No evidence LVH or dilatation
    • No thrill
    • No increase with Valsalva
aortic stenosis1
Aortic stenosis
  • Significantly more likely if Pt has:
    • effort syncope
    • slow carotid rise
    • murmur peak in mid or late systole
    • decreased or absent S2
    • pulse delay
  • Significantly less likely if Pt has:
    • No murmur
    • No radiation to carotid
pre op echo
Pre op ECHO
  • Not an independent predictor
  • Only for standard indications
    • murmur/valvular disease
    • atrial fibrillation/flutter
    • dyspnea/CHF/cardiomyopathy
    • unstable angina

"Only two things are infinite: The universe and human stupidity. And I am not so sure about the former."

Albert Einstein

The courage is knowledge of how to fear what ought to be feared & how not to fear what ought not to be feared
Clues to order echo:
    • Prior CHF or MI
    • Evidence of valvular heart disease
  • Predictive utility only for Revised Cardiac Risk Index III and IV