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Dr Madalina Garbi, FRCP
Consultant Cardiologist
Clinical Head of Echocardiography, South London Healthcare NHS Trust
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NOT APPROPRIATE FOR INNOCENT MURMURS!
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Late peak aortic stenosis murmur
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Murmur of mitral regurgitation fÉâÇw aÉ F
Murmur of pulmonary stenosis
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? Innocent
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? Innocent
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usually mid‐systolic, musical, not associated with structural abnormalities of clinical significance
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Cardiologists: 67% sensitivity for innocent murmurs (University of Zurich Hospital, Am J of Medicine, June 2008) •
All levels of seniority: 30% diagnostic accuracy for murmurs
67%‐100% sensitivity for systolic murmurs 21%‐100% sensitivity for diastolic murmurs
Diagnosis of aetiology of organic murmurs improves with experience
Diagnosis of a murmur as innocent has less correlation with experience (Cardiovascular Medicine, U. of Manchester + Manchester Royal Infirmary + Ealing Hospital, British J of Cardiology, Jan 2010)
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Still’s murmur
Pulmonary flow murmur
Pulmonary branch murmur of infancy
Systemic flow murmur
Venous hum
Mammary souffle
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Still’s murmur: vibratory, musical, mid systolic
Flow murmurs in adults mainly in conditions of hyperdynamic
circulation (anaemia) and during pregnancy
Prevalence of innocent murmurs and pathology in echo for murmurs
In 100 echos for murmurs
Attenhofer Jost et al, Am J of Medicine, June, 2000
GP Open Access Echo Service Audit Oct. 2010, WCH, North Cumbria University Hospitals
Echo ? Innocent murmur – paediatric referrals audit
Oct. 2010 – North Cumbria University Hospitals
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difficult to support and validate •
Flow murmurs
‐generated by turbulent flow through normal structures
‐! turbulent flow not consistently demonstrated (invasive / Doppler)
‐Higher LVOT/RVOT or transvalvular A &P velocities ‐Anaemia, hyperdynamic circulation
‐Increased intraventricular velocities 43,5% (only likely explanation 16,7%)
(Spooner et al, JACC, Nov 1998) & (Murgo, JACC, Nov 1998)
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Musical instruments (McKusick, Cardiovascular sounds in Health and Disease, 1958, Williams and Wilkins)
LV tendons (Malouf et al, 1986, Br Heart J)
TV Septal leaflet chordae (Guntheroth, Am J of Cardiology, April 2009)
LV Tendons = False MV Chordae Tendinae
Redundant and not taut during systole (even at high dose dobutamine)
- doubts that they could generate a murmur -
LV Tendons = False MV Chordae Tendinae
Some tendons attached to the basal part of the anterior interventricular septum and with
more muscular insertion on the lateral wall or with clear attachment to a papillary muscle
can give higher local systolic acceleration of flow resulting in an audible systolic murmur.
In this case see local
intracavitary velocity with
typical late peak but too low
to give a murmur
TV septal leaflet chordae
Taut in systole: musical instrument strings plucked by RVOT flow
Invasive RVOT phonocardiography
TV septal leaflet chordae
TV septal leaflet chordae in RVOT MR – Trivial and early systolic
Can it explain the murmur in a patient referred for “murmur ?cause”
Mild MR but end‐systolic
Can it explain the murmur in a patient referred for “murmur ?cause”
Just to prove that phono works...
Severe AS in young patient
Early systolic trivial MR + trivial AR
none could give an audible murmur – the MR could be only a Doppler artefact but the AR represents pathology Patient referred for “murmur”
mild end‐systolic MR and mild AR
Yearly echo follow-up?
Patient referred for “murmur”
mild end‐systolic MR and mild AR
Yearly echo follow-up?
Patient referred for “murmur”
mild end‐systolic MR and mild AR
Yearly echo follow-up?
Patient referred for “murmur”
mitral valve prolapse with mild end‐systolic MR
Yearly echo follow-up?
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Low score = Inappropriate
In agreement with ESC Guidelines on the management of valvular heart disease: follow‐up
Surprise Diagnosis
Case 1
Referral for “systolic murmur ?cause” reveals AR and...
...doming of the anterior mitral valve leaflet
No explanation for “systolic murmur”
Non-cardiologists often report “systolic murmur” on auscultation in patients with mild
or moderate aortic regurgitation – Stanford University, Clin Cardiol. 2004 Sep;27(9):502-6.
Referral for “systolic murmur ?cause” reveals AR and...
...doming of the anterior mitral valve leaflet
No explanation for “systolic murmur”
Surprise diagnosis: mitral stenosis
Surprise Diagnosis
Case 2
Referral for “systolic murmur ?cause”
RVOT velocity higher than LVOT velocity
Surprise diagnosis: ASD
Case 3
Referral for systolic murmur ?Aortic Stenosis severity
murmur: ejectional, precordial & in the aortic auscultation area
Referral for systolic murmur ?Aortic Stenosis severity
murmur: ejectional, precordial & in the aortic auscultation area
Aortic valve opens well
Increased velocity: aortic sclerosis
? Innocent murmur
increased risk of cardiovascular morbidity and mortality
may develop aortic stenosis
Ngo at al, JACC, March 2009
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New murmur
Mid systolic murmur grade 3 or more
Holosystolic murmur
Mid-late systolic murmur
Systolic murmur which increases with standing or with Valsalva
All diastolic murmurs
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Normal findings = innocent murmur •
Not necessary to attempt to justify the acoustic finding •
Mild disease may be found by echo, related with the murmur or as an incidental finding (e.g. AR)
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Mild disease is to be discharged with advice to be referred back in case of clinical changes
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There are surprise diagnoses WÉ \ {xtÜ ÅÉÜx à{tÇ àãÉ {xtÜà áÉâÇwáR
Caricature in The London Hospital Gazette during bombing in 1941