Murmurs and neonatal cardiology

Question 1

Right sided murmurs

Answer 1

Pulmonary
Tricuspid

Question 2

Left sided murmurs

Answer 2

Aortic
Mitral

Question 3

Ejection systolic murmurs louder on EXPIRATION

Answer 3

aortic stenosis
hypertrophic obstructive cardiomyopathy

Question 4

ejection systolic murmurs louder on INSPIRATION

Answer 4

pulmonary stenosis
atrial septal defect

Question 5

Holosystolic murmurs

Answer 5

Mitral regurgitation
Tricuspid regurgitation
VSD

Question 6

Holosystolic murmur louder on EXPIRATION

Answer 6

mitral regurgitation

Question 7

Holosystolic murmur louder on INSPIRATION

Answer 7

tricuspid regurgitation

Question 8

Late systolic murmurs

Answer 8

mitral valve prolapse
coarctation of aorta

Question 9

early diastolic murmurs

Answer 9

aortic regurgitation (high-pitched and blowing in character)
Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)

Question 10

Mid-late diastolic murmurs

Answer 10

mitral stenosis (‘rumbling’ in character)
Austin-Flint murmur (severe aortic regurgitation, again is ‘rumbling’ in character)

Question 11

Continuous machine-like murmur

Answer 11

Patent ductus arteriosus

Question 12

Clinical features of aortic stenosis

Answer 12

chest pain
dyspnoea
syncope / presyncope (e.g. exertional dizziness)
murmur (ejection systolic)classically radiates to the carotids
this is decreased following the Valsalva manoeuvre

Question 13

Features of severe aortic stenosis

Answer 13

narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure

Question 14

Causes of aortic stenosis

Answer 14

degenerative calcification (most common cause in older patients > 65 years)
bicuspid aortic valve (most common cause in younger patients < 65 years)
William’s syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM

Question 15

Management of aortic stenosis

Answer 15

if asymptomatic then observe the patient, if symptomatic then valve replacement

if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

Question 16

Surgical aortic valve replacement options?

Answer 16

1. if the patient is well - AVR
2. Operative risk: transcatheter AVR (TAVR) is used for patients with a high operative risk

Question 17

Aortic regurgitation causes

Answer 17

Valve disease:
rheumatic fever: the most common cause in the developing world
calcific valve disease
infective endocarditis
connective tissue diseases e.g. rheumatoid arthritis/SLE
bicuspid aortic valve (affects both the valves and the aortic root)

Aortic root disease:
bicuspid aortic valve (affects both the valves and the aortic root)
aortic dissection
spondylarthropathies (e.g. ankylosing spondylitis)
hypertension
syphilis
Marfan’s, Ehler-Danlos syndrome

Question 18

features of aortic regurgitation

Answer 18

early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams

Question 19

Management of aortic regurgitation

Answer 19

medical management of any associated heart failure
surgery: aortic valve indications include
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunction