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Echo assessment & approach of continuous & diastolic murmur
- 1. Echocardiographic assessment of continuous & diastolic murmur
- 2. INDEX • Continuous murmur – Definition – Approach to differential diagnosis – Echo assessment of individual lesions • Diastolic murmur – Approach to differential diagnosis – Echo assessment of individual lesions
- 3. • A continuous murmur is one, which begins in systole and extends uninterrupted into diastole not necessarily occupying the whole length of systole and diastole • Implies a pressure difference in both systole & diastole
- 5. Characteristics Continuous murmur To-and-fro murmur Combined systolic and diastolic murmur Direction of flow Unidirectional, single murmur Systolic in one direction and diastolic in reverse direction. Two separate murmurs from same valve Not through same orifice or valve. Combination of different orifices or valves producing two murmurs Classic example PDA AS AR VSD AR S2 masked separate separate Source of murmur Extracardiac or extracardiac to cardiac shunt mostly intracardiac intracardiac Gap at S2 Absent Present present
- 7. CM Acyanotic Above clavicle Normal heart sounds Disappea rs with lying down or on compress ion of jugular vein Venous hum 2nd Left ICS below clavicle No distinct S1 S2 Doesno t disapp ear PDA Mid to lower rt/lt PS Aortic run off- Coronary AVF aortic run off+ RSOV Small APW Extracar diac Systemi c AV fistula Cyanoti c Pre op Heart sounds normal Pulmon ary AVF Heart sound s not norm al TAPVC Post op Over back & widely heard AP collaterals 2nd ICS infracl avicul ar PS BT shunt
- 8. Continuous murmur Rapid blood flow High to low pressure shunts Localized arterial obstruction 1. Cervical venous hum 2. Mammary souffle 3. Hyper thyroidism 4. Heamngiom a 1. COA 2. Branch PA stenosis 3. FA occlusion Aortic runoff into PA 1.PDA 2.AP window 3.After shunt surgery 4.AP collaterals SA to PA 1.RSOV into RA or RV 2.Coronary cameral fistula SA to right heart Other shunts : 1.Lutembacher syndrome 2.AV fistula 3.Anomalous PVD
- 9. Diastolic murmur PDA RSOV Coronary AVF Small APW Venous Hum Systemic AVF S2 Murmur peaks at S2, masks it No peak at S2 Murmur peaks during systole, not at S2 No peak at S2 Normal Normal Murmur multiple systolic clicks Present through out cardiac cycle without a break Present through out cardiac cycle without a break, No multiple clicks Disappears with lying down or on compression of jugular vein Rustling character, a/w bruit Grade 2-4 5-6 2-6 3-6 1-2 2-4 Best heard at 2nd Left ICS below clavicle Mid to lower rt/lt PS 3,4,5th rt/lt PS 3rd Lt PS Just above clavicle on Rt side Local sites- brain, liver, extremities Systolic component Crescendo & harsh Louder smooth Louder Diastolic component Decrescend o & smooth Louder if a/w AR Louder, smooth Louder & harsh
- 10. AP collaterals BT shunt PAVF TAPVC Best heard at Widely distributed on chest & back 2nd ICS infraclavicular area Superficially heard at a local site CM at site of obstruction/PG Grade Grade 1-3, ESM Grade 1-3 Grade 2-4` Grade 2-3 Soft Prominent locally
- 11. Echo assessment of PDA 1. Position, size, and course of the PDA 2. Direction of ductal flow 3. Measure the peak systolic velocity of flow though the PDA(PA pressure) 4. Assess for potential aortic coarctation. Also assess the origin of the left subclavian artery 5. Evaluate for diastolic flow reversal 6. Evaluate branch PAs 7. Evaluate LA/LV size and function 8. Arch sidedness and head vessel branching
- 18. RSOV • Best audible at: – To RA- RLSB – To RV-LLSB – To RVOT- LUSB • Auscultatory features quite variable: 1. Systolic component louder than diastolic 2. If RSOV to RV is obstructed bcoz of systolic contraction, diastolic component louder 3. Again, if a/w VSD, superimposition of PSM of VSD results in louder systolic component • RSOV murmur generally of grade 5/6, PDA murmur 3-4/6
- 19. Echo assessment of RSOV 1. 2D & color imaging of RSOV – Mosaic color flow turbulence 2. Chamber receiving shunted blood 3. Volume overloading of chamber 4. Associated AR 5. Associated VSD 6. TTE<TEE to assess 1. max diameter of aortic end 2. minimum diameter & length of windsock 3. distance between aortic end to coronary ostium
- 23. AP window • Very rare, as systolic & diastlic pressures are generally equal as defect is large • If small APW, can have continuous murmur • Loud murmur located at 3rd Lt PS space, loud systolic component, does not peak at S2 • Shorter diastolic component of the murmur.
- 24. Echo assessment of APW • Define – 1. Size of defect 2. Color Doppler – – To confirm a true communication – Not just artifactual drop-out 3. Extent of inferior and superior rims 4. Involvement of RPA ? 5. A/w other cardiac defects? in 25-50% of cases – include: TOF, aortic arch anomalies (COA, type A IAA), ALCAPA, tricuspid, aortic or pulmonary atresia, and TGA
- 28. Coronary AVF • The location, duration, and character of the continuous murmur depend upon the anatomical type of fistula. • The right coronary and right atrial, or coronary sinus communication produces a murmur located along the parasternal area. • The murmur of circumflex coronary artery and coronary sinus communication is located in the left axilla. • The configuration of the murmur and its systolic and diastolic intensities are variable.
- 29. Coronary AV fistula • Best audible at: – RA-RLSB or RUSB – LA-ULSB rad to Lt ant ax line – CS- back B/w spine & Lt scapula – Lt SVC –upper to mid LSB – RV inflow –LLSB – RVOT –upper to mid LSB – PA – ULSB • Smooth murmur, no harsh components, unlike PDA • Murmur peaks during systole, not at S2 • No wide pulse pressure
- 30. Echo assessment of CAVF 1. Origin from coronary artery 2. Coronary connection to aorta 3. Drainage chamber 4. Coronary artery size/dilation 5. LA/LV dialation 6. Ventricular function
- 33. Coarctation of Aorta • CM only in very severe coarct • Collateral murmur, mainly at back • Quite rare, systolic difference +, but diastolic pressures almost equal • Since ESM of CoA is delayed in onset, bcoz of time required for the impulse to travel from Aortic valve to site of obstruction, it may appear that murmur is going through S2, hence continuous • Continuous murmur can be bcoz of associated PDA
- 34. Echo assessment of COA • Indentation of posterior aorta by shelf • Proximal, transverse, isthmus, DAO at diaphragm dimensions • Presence & size of PDA • Doppler interrogation • Distance of coarct from LSCA
- 38. Peripheral PS • Very rarely, can have continuous murmur • Loud systolic component • Sounds like a venous hum
- 40. Venous hum • Present in upto 40% normal children below 5yrs of age • Turbulence of blood in jugular veins • Thoracic inlet is small, so jugular veins get compressed • Upper right sternal border & in neck • Disappear with pressure/lying down/turning neck to left side
- 41. Venous hum • Present in upto 40% normal children below 5yrs of age • Turbulence of blood in jugular veins • Thoracic inlet is small, so jugular veins get compressed • Upper right sternal border & in neck • Disappear with pressure/lying down/turning neck to left side
- 42. BT shunt • H/o surgery, presence of surgical scar & a continuous murmur in Rt/Lt upper sternal border
- 43. Echo assessment of BT shunt • Suprasternal view 2D & color • Doppler interrogation for PA pressure
- 46. Pulmonary AVF • The murmur is usually softer and may be primarily systolic. It is usually audible over the back with cyanosis and clubbing present in the absence of cardiomegaly.
- 47. Pulmonary AV fistula • Audible as a venous hum localised to a chest area • Murmur in multiple areas over chest if a/w multiple AVF • Agitated saline test
- 48. Echo assessment of PAVF
- 50. Hemi truncus
- 52. Bronchial collaterals/PDA in TOF • Continuous murmur mainly in back but can be present all over the chest/axilla as well • Continuous murmur of collaterals identify normal PA pressure/potentially surgically correctable lesion • PDA identified by its usual characteristics • PDA & collaterals both generally not present simultaneously
- 53. TAPVC • Continuous murmur indicates unobstructed TAPVC • Indicates large flow through a normal but dilated left innominate vein • Venous hum type continuous murmur at suprasternal notch/rt sternal border
- 54. Echo assessment of TAPVC • Goals of the echocardiographic examination 1. Establish the diagnosis; 2. Image and determine the size of the individual pulmonary veins; 3. Ascertain that none of the pulmonary veins drain separately 4. Image and determine the relation of the pulmonary venous confluence with LA;
- 55. 5.Image the course of the pulmonary venous channel (usually the vertical vein ), its connection with systemic vein & its relation to neighboring structures (i.e., pulmonary arteries and airways); 6.Determine whether there is obstruction to pulmonary venous flow; 7.Evaluate the interatrial communication for obstruction 8.Exclude additional structural cardiac anomalies
- 56. TAPVC
- 58. AP collateral
- 59. Hemi truncus
- 61. AR
- 62. DM Parasternal Aortic run off + AR Aortic run off - Loud S2, RV heave, cyanosis, clubbing Hypertensive PR Normal S2 Non hypertensive PR Apical Narrow pulse, Diastolic Thrill+, Mainly DM only MS Hyperdynamic precordium, A/w systolic/continuous murmur Large LR shunt
- 63. Diastolic Murmur Early DM AR PR with PAH Delayed DM PR without PAH LV/RV inflow obstruction MS LA myxoma MV opening interference Austin flint murmur Flow murmurs Large VSD, PDA Late DM MS
- 65. Echo assessment of AR 1. Aortic valve morphology 2. Severity of AR 3. Aortic root dimensions 4. LV dimensions 5. LVEF
- 69. Echo For ES 1. CW of TR velocity + other echo signs of PH 2. other echo signs of PH – 1. PR velocity 2. Dilated RA, PA 3. RV/LV basal diameter ratio >1 4. Flattening of IV septum
- 70. 1. Defines the defect (PDA may be difficult) 2. Estimates PA pressure by TR/PR jets 3. Contrast echo demonstrates RL shunting 4. TEE is safe and may be required in adults for precise delineation of the abnormality
- 71. Echo assessment of PR
- 72. Echo assessment of mitral stenosis 1. Valvar/subvalvar/supravalvar apparatus 2. Mean gradient across mitral valve 3. Leaflet mobility 4. Tip thickening 5. MV area 6. Associated MR 7. Pulmonary hypertension 8. EF slope
- 74. MS
- 76. Thank You