Heart murmurs are peculiar sounds that usually occur when pathological conditions, but sometimes in healthy people.
Unlike heart sounds, which are regular, rapidly decaying sound vibrations perceived as a short sound, heart murmurs are irregular sound vibrations that do not decay for a long time and are perceived as a long sound.
Classification of heart murmurs
Intracardiac and extracardiac murmurs are distinguished according to the place of origin.
Intracardiac murmurs occur when conditions are created for their appearance inside the heart itself:
defects in the valvular apparatus of the heart, leading to narrowing of the openings between the cavities of the heart or to narrowing of the pathways for the outflow of blood from the ventricles of the heart into the great vessels;
defects in the valvular apparatus of the heart, leading to regurgitation of blood flow from great vessels into the ventricles of the heart or from the ventricles of the heart into the atria;
acquired lesions of large vessels - aortic atherosclerosis, syphilitic mesaortitis, aortic aneurysm;
congenital defects in the structure of the heart that disrupt intracardiac hemodynamics - ventricular septal defect (Tolochinov-Roger disease), stenosis of the left atrioventricular orifice and patent oval window (atrial septal defect) - Lutembashe disease;
congenital defects of large main vessels, aorta and pulmonary artery: patent ductus arteriosus, or patent ductus arteriosus; isolated
with pulmonary artery stenosis (valvular stenosis; subvalvular - infundibular stenosis - narrowing of the pulmonary artery trunk);
isolated stenosis of the aortic mouth (valvular, subvalvular - infundibular stenosis and supravalvular - rarely); Coarctation of the aorta is a congenital narrowing in a limited area, located slightly distal to the origin of the left subclavian artery from the aorta;
congenital combined defects in the structure of the heart and large vessels, for example triad, tetralogy or pentade of Fallot (narrowing of the outflow tract from the right ventricle, defect of the interventricular
daughter septum, change in the position of the initial part of the aorta with its origin above the defect in the septum, hypertrophy of the right ventricle);
damage to the heart muscle (myocarditis, myocardial infarction, cardiosclerosis, dilated cardiomyopathy), leading to a decrease in its tone. In this case, noise is caused by
2 mechanisms: 1) weakening of the papillary muscles that hold the valve leaflets; 2) expansion of the heart chambers (myogenic dilatation), as a result of which the opening between the cavities of the heart widens and the leaflets of unchanged valves are not able to close it;
violation of the rheological properties of blood - a decrease in its viscosity during anemia, when the speed of blood flow increases and turbulence appears as blood passes through the holes
hearts;
an increase in the speed of blood passage through the heart in certain pathological conditions (thyrotoxicosis, infectious diseases, neurocirculatory dystonia).
Extracardiac murmurs: 1) pericardial friction murmur; 2) pleuropericardial murmur; 3) cardiopulmonary murmur. These noises will be discussed in more detail below.
Based on the reason for their occurrence, they distinguish between: a) organic and b) inorganic, or functional, or innocent noises.
Organic murmurs are formed due to the presence in the heart of organic defects of acquired or congenital origin.
To date, it has been proven that both valve insufficiency and stenosis of the orifices are caused by the development of sclerotic changes. Their causes may be rheumatism,
atherosclerosis, infective endocarditis, syphilis, systemic lupus erythematosus.
Functional intracardiac murmurs are caused by a weakening of the tone of the heart muscle, a violation of the rheological properties of the blood, and an acceleration of blood flow. Thus, these murmurs reflect quite serious changes in the heart muscle or in the nature of blood flow and can only rarely occur in healthy people (see below for more details).
In addition, murmurs are divided depending on the phases of cardiac activity: systolic - occurs in systole, determined between the 1st and 2nd sounds; diastolic - occurs in
diastole, determined between the II and I sounds; systole-diastolic - occupies the periods of both systole and diastole.
An example of a systolic-diastolic murmur is the murmur of a patent ductus arteriosus. In this case, the systolic component of the noise is always longer and louder than the diastolic one; the noise has a peculiar timbre - “machine” noise.
Variants of systolic murmur
Pansystolic murmur - occupies the entire systole and merges with the sounds.
Early systolic murmur.
Median systolic murmur, or mesosystolic.
Late systolic murmur.
Holosystolic murmur - occupies the entire systole, but does not merge with the 1st and 2nd sounds.
Functional murmurs, unlike organic ones, are never pansystolic, but occupy only part of the systole.
Variants of diastolic murmur
Protodiastolic. Occurs at the beginning of diastole immediately after the second sound. Associated with insufficiency of the aortic valves and pulmonary valves, since protodiastole occurs
their closure.
Mesodiastolic. Occurs in mid-diastole with pronounced insufficiency of the mitral or tricuspid valves (functional Coombs murmur).
Presystolic. Occurs at the end of diastole before the first sound, more often with mitral stenosis.
Pandiastolic - occupies the entire diastole.
The systolic murmur coincides in time with the apical impulse and the pulse in the carotid artery, and the diastolic murmur coincides with the long pause of the heart preceding the first sound.
Mechanisms of noise generation
There are 7 options for the occurrence of noise.
1. Narrowing of the vessel in a limited area. Fluid turbulence occurs and noise is generated (narrowing of the atrioventricular orifices, aortic orifices, pulmonary artery, coarctation
aorta, etc.). However, with a sharp narrowing of the lumen, the noise is not heard, an example of which is “aphonic” mitral stenosis.
2. Dilation of the vessel in a limited area. Vortex movements of the blood are formed (aneurysm of the aorta and other large vessels).
3. Fluid flow in the opposite direction - regurgitation, reflux (insufficiency of the mitral, tricuspid and semilunar valves of the aorta and pulmonary artery).
4. Model of communicating vessels (patent ducts, arteriovenous aneurysms, etc.).
The remaining 3 mechanisms are associated with functional noise; their occurrence is due to:
5. Decreased myocardial tone.
6. Reduced blood viscosity.
7. Increasing the speed of blood flow.
Taking into account these mechanisms, murmurs in organic heart defects are divided into the following:
1. Return noise (regurgitation) - with valve insufficiency (mitral, aortic, tricuspid, pulmonary).
2. Ejection sounds - with stenosis of the orifices and orifices (left and right atrioventricular orifices and the orifices of the aorta and pulmonary artery).
3. Filling noises - with stenosis of the left and/or right atrioventricular orifices at the time of filling of the ventricles at the beginning of diastole due to acceleration of blood flow from the atria
due to the high pressure gradient.
Characteristic intracardiac murmurs heart should be reflected by the following data:
a) in what phase of cardiac activity does the murmur occur?
b) the place of his best listening,
c) noise transmission area,
d) noise intensity,
e) duration of noise,
e) timbre of noise,
g) changes in noise intensity,
h) the presence or absence of chest wall tremors accompanying the noise.
NOISE PHASE
Systolic murmur is most often recorded in the following pathologies.
Acquired heart defects:
1. Stenosis of the aortic mouth.
2. Mitral valve insufficiency.
3. Tricuspid valve insufficiency.
Congenital heart defects:
1. Narrowing of the mouth of the pulmonary artery.
2. Ventricular septal defect (VSD).
3. Atrial septal defect (ASD).
4. Coarctation of the aorta and other rare pathologies.
Aortic pathologies:
1. Atherosclerosis of the ascending aorta.
2. Aortic aneurysm.
3. Syphilitic mesaortitis.
Diastolic murmur is recorded with the following acquired heart defects.
1. Narrowing of the mitral orifice.
2. Narrowing of the right atrioventricular opening.
3. Insufficiency aortic valve.
4. Pulmonary valve insufficiency. Most often, relative pulmonary valve insufficiency occurs due to post- and precapillary pulmonary hypertension.
Murmurs at the apex of the heart (at the 1st point) are most often associated with damage to the mitral valve or stenosis of the left atrioventricular orifice.
1. Systolic murmur - with insufficiency or prolapse of the mitral valve.
2. Diastolic murmur - with stenosis of the left atrioventricular orifice.
3. Systolic and diastolic murmurs - with complex (combined) mitral disease. The predominance of any noise may indirectly indicate the predominance of a particular defect.
Noises at the 2nd point (on the right at the sternum in the I intercostal space).
1. Systolic - for stenosis of the aortic mouth, atherosclerosis, aortic aneurysm, syphilitic mesaortitis.
2. Diastolic - with aortic valve insufficiency, but the murmur with this defect is better heard at the 5th point.
3. Combination of systolic and diastolic - for complex (combined) aortic disease.
Noises at the 3rd point (on the left at the sternum in the 2nd intercostal space).
1. Systolic murmur - when the mouth of the pulmonary artery is narrowed.
2. Diastolic (Graham-Still murmur) - with relative insufficiency of the pulmonary valves.
3. Systole-diastolic - when the arterial (botallian) duct is not closed.
Noises at the 4th point (on the lower third of the sternum at the base of the xiphoid process) - damage to the tricuspid valve.
1. Systolic - with tricuspid valve insufficiency.
2. Diastolic - with narrowing of the right atrioventricular opening. However, this noise is best detected in the third intercostal space at the right edge of the sternum.
Murmurs at the 5th point (at the left edge of the sternum in the third intercostal space) are characteristic of damage to the aortic valves.
Functional noise
These noises are caused by 3 groups of reasons: 1) damage to the heart muscle with expansion of the heart cavities, a decrease in the tone of the papillary muscles and expansion of the fibrous rings between the cavities
hearts; 2) acceleration of blood flow; 3) decreased blood viscosity.
Characteristics of functional noise:
in the vast majority of cases they are systolic;
the timbre is soft, blowing;
fickle;
are localized and are not carried out beyond the zone of occurrence;
are not accompanied by chest trembling.
Functional noises associated with acceleration of blood flow occur during febrile states, vegetative-vascular dystonia, thyrotoxicosis, and tachycardia of other etiologies.
Functional noises associated with a decrease in blood viscosity are observed in anemia and are called hydremic functional noises.
The following functional murmurs are distinguished, caused by the expansion of the cavities of the heart (myogenic functional murmurs).
1. Systolic murmur at the apex (1st point) with relative mitral valve insufficiency (with stenosis of the aortic mouth, aortic valve insufficiency, myocarditis, infarction
myocardium, arterial hypertension, etc.).
2. Systolic murmur on the lower third of the sternum at the base of the xiphoid process (4th point), associated with relative insufficiency of the tricuspid valve (myogenic
dilatation of the right ventricle with myocarditis, dilated cardiomyopathy, postcapillary and/or precapillary pulmonary hypertension, mitral stenosis, chronic pulmonary
heart, etc.).
3. Protodiastolic Graham-Still murmur in the left 2nd intercostal space (3rd point) with mitral stenosis due to the development of relative pulmonary valve insufficiency
due to high pulmonary hypertension.
4. Presystolic Flint murmur at the 1st point with aortic valve insufficiency. The origin of the murmur is associated with functional mitral stenosis, which occurs due to the fact that the jet of blood from the aorta during regurgitation lifts the mitral valve leaflet towards the flow of blood from the atrium.
Extracardiac murmurs
1. Pericardial friction noise.
2. Pleuropericardial murmur.
3. Cardiopulmonary murmur (“systolic breathing” Po-
tena).
Accordingly, in such a situation it is very difficult to distinguish systole from diastole using auscultation. This happens because severe volume overload of the left ventricle prolongs the ejection period, and the diastolic period can become even shorter due to tachycardia. In order not to confuse systole with diastole, it is recommended to simultaneously palpate the carotid pulse or apex beat with auscultation.
2. Why, with sudden onset of severe aortic regurgitation, the murmur may not be pandiastolic even in cases where the diastole becomes shorter than normal? In sudden severe aortic regurgitation, the left ventricle does not dilate to the same extent as in chronic aortic regurgitation. In other words, in the first case, the left ventricle is less distensible due to the inability of the pericardium to rapidly stretch. In fact, left ventricular pressure during diastole can increase so significantly and so quickly that it can even become equal to the mesodiastolic pressure in the aorta. Equality of intra-aortic and intraventricular pressure limits the amount and duration of aortic regurgitation that can occur (see Fig.
9 on page 396). The murmur of aortic regurgitation may not only be short (not pan-diastolic), but also surprisingly quiet.
Differential diagnosis 1. What murmurs most often mimic the murmur of aortic regurgitation? A. Pulmonary regurgitation murmur caused by high pressure in the pulmonary artery (Graham Still's murmur).
b. High-frequency components of murmurs of mitral stenosis, conducted to the left edge of the sternum.
2. What murmurs in rare cases can imitate the murmur of aortic regurgitation? A. Diastolic component of a quiet continuous murmur due to a fistula coronary artery with the pulmonary artery or right coronary artery with the left ventricle, in cases where the systolic component of this murmur is not heard.
b. Inflation of the intra-aortic balloon pump during diastole produces a short, slightly delayed diastolic murmur of a wind-like or roaring timbre.
V. The flailing posterior leaflet of the mitral valve during a rapid transition from a prolapsed position (in the left atrium) to an open position (in the left ventricle), pushing blood from the left atrium into the left ventricle.
d. Similar to the murmur of aortic regurgitation, a quiet diastolic murmur is heard in the second or third intercostal space to the left of the sternum in some patients with moderate (occlusion of no more than 50%) obstruction of the anterior descending coronary artery.
murmurs with stenosis of the anterior descending coronary artery 1. What are they? characteristics diastolic murmur in coronary artery stenosis? This noise:
A. High-frequency and increasingly decreasing in accordance with the pattern of diastolic coronary blood flow, which is maximum in the first quarter of diastole.
b. It is easiest to hear with the patient in a sitting position.
Note:
It has been observed that this murmur may disappear after myocardial infarction and coronary artery bypass grafting.
The diastolic murmur of coronary artery stenosis indicates that the obstruction is minor, i.e. such that the remaining blood flow is sufficient to produce turbulence that can become a source of diastolic murmur.
It is not surprising that all patients studied with this murmur had an obstruction rate of less than 50%.
PULMONARY REGURGITATION murmurs High pulmonary artery pressure murmurs (Graham Still's murmur) 1. Does the pulmonary artery pressure have to be very high for a pulmonary regurgitation murmur to occur? Usually pulmonary pressure is very high (i.e. close to systemic blood pressure). Pulmonary regurgitation murmurs rarely occur when pulmonary artery pressures are below 80 mmHg. Art., except in cases where the pulmonary trunk is significantly dilated.
Notes:
A. A Graham Still murmur is a murmur of pulmonary regurgitation that occurs in the setting of pulmonary hypertension, regardless of whether the pulmonary hypertension is primary or secondary.
b. The murmur of pulmonary regurgitation due to a ventricular septal defect can occur even with normal pulmonary vascular resistance if the pulmonary artery pressure exceeds 80 mm Hg. Art.
2. How does a Graham Still murmur differ from an aortic regurgitation murmur? These noises may not be different. In other words, both noises are predominantly high-frequency, can vary in intensity from 1 to degree, at first be increasingly decreasing and - if the intensity is low - become louder on exhalation. At the same time, if the volume of Graham Still's noise is high, it usually intensifies during inspiration (Fig. 13).
Rice. 13. Phonocardiograms of a patient with persistent ductus arteriosus, in whom the pulmonary artery pressure was 145 mm Hg, are presented. Art., and aortic pressure was approximately the same. A loud diastolic murmur (Graham Still's murmur) recorded on phonocardiograms increased significantly during inspiration. The quiet Graham Still noise may not increase during inspiration. HF - high frequencies, MF - mid frequencies Notes:
A. If the volume of the Graham Still murmur is insignificant, then during inspiration it may decrease even more, despite the increase in blood flow in the pulmonary artery. The fact is that the quiet noise of pulmonary regurgitation is usually best heard in the second intercostal space to the left of the sternum, and the increase in the distance between the stethoscope and the heart that occurs during inspiration in this area is most pronounced. In addition, in severe pulmonary hypertension, inspiratory blood flow to the lungs may not increase if there is concomitant tricuspid regurgitation b. Isometric hand clenching and squatting will selectively increase the volume of the aortic regurgitation murmur.
3. How does the Valsalva maneuver help distinguish the murmur of pulmonary regurgitation from the murmur of aortic regurgitation? Immediately after cessation of straining, the volume of the pulmonary regurgitation noise becomes the same as before the Valsalva maneuver. The initial loudness of the murmur of aortic regurgitation is restored only after four or five cardiac cycles.
Notes:
A. In patients with pulmonary artery dilatation, an early diastolic decaying grinding sound may be heard in the absence of aortic or pulmonary regurgitation. This creaking sound is of extracardiac origin and may be caused by adhesions between the pulmonary artery and surrounding lung tissue.
b. Previously, there was a misconception that a Graham Still murmur was often heard in mitral stenosis because the murmur of aortic regurgitation was incorrectly regarded as being due to pulmonary regurgitation.
Pulmonary regurgitation murmurs with normal pulmonary artery pressure (primary pulmonary regurgitation) 1. Besides the congenital absence of the pulmonary artery, what are the two most common reasons murmurs of primary pulmonary regurgitation? A. Idiopathic dilatation of the pulmonary artery. (Some reports suggest that approximately one third of patients with idiopathic pulmonary artery dilation have pulmonary regurgitation.) b. Surgical treatment of pulmonary artery stenosis. After pulmonary commissurotomy, pulmonary regurgitation of varying degrees always occurs.
Notes:
A. In patients with tetralogy of Fallot and pulmonary regurgitation, the pulmonary valve is almost always absent, and the obstruction of the latter is caused by a narrowed valve ring.
b. Sometimes observed with an atrial septal defect, pulmonary regurgitation may actually be one of the manifestations caused by combined idiopathic dilatation of the pulmonary artery. In one case series, a small number of patients with an uncomplicated atrial septal defect had an early diastolic murmur recorded externally at the base of the heart and on intracardiac phonocardiography exclusively in the right ventricular outflow tract. In another study, in 40% of patients over 20 years of age with an uncomplicated atrial septal defect, a mid-frequency diastolic murmur with an intensity of grade 2 out of 6 was heard, aggravated by inspiration, loudest in the second intercostal space to the left of the sternum and conducted to the right edge of the lower part of the sternum.
V. It has been established that a diastolic murmur that begins simultaneously with the pulmonary component of the second sound near the left edge of the lower part of the sternum in some patients with an atrial septal defect and normal pulmonary artery pressure sometimes represents a diastolic component of a continuous murmur arising at the defect and caused by a combination of high pressure in the left atrium due to mitral regurgitation with small or medium-sized atrial septal defect.
d. Stenosis and/or regurgitation of one or more valves may be caused by long-term use of ergot alkaloids for migraine. In this case, the valve leaflets thicken and tighten, but do not calcify.
2. What are the differences between a primary pulmonary regurgitation murmur and a Graham Still murmur in terms of shape, duration, and frequency? A. With high pulmonary artery pressure, the shape, duration and frequency of the pulmonary regurgitation murmur are the same as with aortic regurgitation. With normal pulmonary artery pressure, there is sometimes a slight delay between the pulmonary component of the second sound and the appearance of any murmur. However, if the noise begins simultaneously with the pulmonary component of the second tone, then such noise is most often short and rough due to the predominance of mid- and low-frequency sound vibrations in its composition.
b. If pulmonary regurgitation is insignificant, then the noise in its characteristics may occupy an intermediate position between the Graham Still noise and the noise of primary pulmonary regurgitation. That is, it may start earlier, last longer, and be of higher frequency than the murmur of more severe primary pulmonary regurgitation.
V. In one study, intracardiac phonocardiography demonstrated that there was no pause between the pulmonary component of the second sound and the appearance of the murmur. At the same time, according to another similar study, the murmur of pulmonary regurgitation occurs with a significant delay.
d. Immediately after the regurgitant pulmonary valve closes, right ventricular pressure drops rapidly, the pressure gradient between the pulmonary artery and right ventricle increases, and the volume of the murmur increases (rising phase). This happens until the right ventricular pressure reaches its minimum. After this, the gradient across the pulmonary valve decreases rapidly and the murmur becomes less loud (waning phase). Thus, the murmur of pulmonary regurgitation with normal pulmonary artery pressure is a short, increasing mid-frequency murmur, because in this case the pressure gradient is not as great as with the high-frequency murmurs of pulmonary hypertension that occur against the background of pulmonary hypertension (Fig. 14).
Rice. 14. This primary pulmonary regurgitation murmur, recorded in a teenage boy, occurred in early diastole and included many mid- and low-frequency sound vibrations. It did not increase with inspiration in the second intercostal space to the left of the sternum because there was too much pneumatized lung tissue in this area between the stethoscope and the heart. The murmur was less loud near the left lower sternal border, although at this location it should have become louder during inspiration 3. Why is the murmur of primary pulmonary regurgitation short? Diastolic pressure in the pulmonary artery falls rapidly because its decrease begins from normal values (which correspond to the incisura on the pulmonary sphygmogram), and diastolic outflow of blood occurs in two directions. As a result, the pressure in the pulmonary artery and right ventricle quickly becomes equal.
Note:
It has been established that pulmonary regurgitation is caused to a greater extent by deformation rather than dilatation of the annulus fibrosus of the pulmonary valve.
PERICARDIAL FRICTION NOISE Pericarditis 1. What mechanism causes the occurrence of pericardial friction noise? It is generally believed that friction sounds are caused by two hard layers of the pericardium (visceral and parietal) rubbing against each other. If the surrounding pleura is also involved in the pathological process, then the cause of the noise may be the friction of the pleura with outer surface pericardium. The murmur that occurs in such cases is a pleuropericardial friction murmur.
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All functional noises are conventionally divided into three groups:
Dynamic, which occur with a significant increase in the speed of blood flow through the normal openings of valves or great vessels (for example, dynamic noises during thyrotoxicosis, febrile conditions);
Anemic, associated with a decrease in blood viscosity and some acceleration of blood flow in patients with anemia of various origins;
Noises of relative valve insufficiency or relative narrowing of valve openings.
Often dynamic and anemic noises are combined with the concept of “innocent noises”, since they occur in the absence of any organic diseases hearts.
Functional murmurs of relative valve insufficiency or relative stenosis of the valve openings in most cases are caused by expansion of the fibrous ring of the AV valves with pronounced dilatation of the ventricles, dysfunction of the valve apparatus (chordae and papillary muscles), hemodynamic displacement of the valve leaflets, dilatation of the aorta or pulmonary artery(eg, functional diastolic Graham-Still murmur).
- Expansion of the fibrous ring of the AV valves with severe dilatation of the ventricles leads to incomplete closure of anatomically unchanged AV valve leaflets and the development of relative insufficiency of these valves with turbulent blood flow from the ventricles to the atria. The characteristics of the noise of relative insufficiency of the mitral and tricuspid valves in these cases are similar to those with corresponding organic defects (see above).
- Relative mitral valve insufficiency can develop with LV dilatation in patients with hypertension, aortic heart disease, mainly in the stage of decompensation (the so-called “mitralization” of aortic disease), in patients with congestive heart failure of any origin. Relative tricuspid valve insufficiency, caused by pancreatic dilatation, often develops in late stages mitral stenosis and decompensated cor pulmonale. The functional murmur of regurgitation is detected in patients with dysfunction of the valve apparatus (chordae and papillary muscles), for example, with infarction of the papillary muscle, congenital elongation or acquired rupture of one of the chordae of the AV valves. In these cases, prolapse (protrusion, sagging) of one of the leaflets into the atrium cavity develops during ventricular systole. This leads to incomplete closure of the leaflets and the development of relative insufficiency of the AV valve. In this case, a short systolic murmur (usually meso- or late systolic) is heard, usually with the first sound preserved.
- Graham-Still noise - functional diastolic murmur of relative pulmonary valve insufficiency, which occurs with a prolonged increase in pressure in the pulmonary artery (for example, in patients with mitral stenosis, primary pulmonary hypertension, cor pulmonale). In the second intercostal space to the left of the sternum and along the left edge of the sternum, a quiet, decreasing diastolic murmur is heard, starting immediately with the second sound.
- Flint noise - presystolic murmur of relative (functional) stenosis of the left AV orifice, which sometimes occurs in patients with organic insufficiency of the aortic valve due to elevation of the mitral valve leaflet by a strong stream of blood flowing from the aorta to the LV during diastole. This leads to obstruction of blood flow from the LA to the LV during active atrial systole. At the same time, at the apex of the heart, in addition to the wired organic diastolic murmur of aortic insufficiency, presystolic amplification of the murmur, the functional Flint murmur, is also heard.
- Coombs noise - functional mesodiastolic murmur caused by relative stenosis of the left AV orifice, which occurs in patients with severe organic mitral valve insufficiency under conditions of significant dilatation of the LV and LA and the absence of expansion of the fibrous annulus of the valve. Under these conditions, the heart (LV and LA) resembles an hourglass shape with a relatively narrow “bridge” in the area of the left AV orifice. At the moment of LA emptying in the rapid filling phase, this hole is on a short time becomes relatively narrow for the increased blood volume, and relative stenosis of the left AV orifice occurs with turbulent blood flow from the left atrium. At the apex of the heart, in addition to the organic systolic murmur of mitral insufficiency, you can listen to a short and quiet mesodiastolic murmur caused by functional mitral stenosis, as well as functional murmurs with abnormally located chords (trabeculae) of the LV, the tension of which leads to the occurrence of systolic murmur.
A.V. Strutynsky
Complaints, anamnesis, physical examination
CLASSIFICATION AND CLINICAL CHARACTERISTICS.
AUSCULTATION OF THE HEART. HEART NOISE. MECHANISM OF THEIR FORMATION.
LECTURE
In addition to sounds, sounds can be heard during auscultation of the heart.
phenomena called heart murmurs. Change of conditions, not
necessary for normal blood flow in the heart and large vessels,
leads to the appearance of additional sound phenomena located in
close relationship with certain phases cardiac cycle.
Based on the physical properties of noise, the latter is characterized by more
longer and slowly fading than tones, aperiodic co-
vibrations forming a continuous spectrum.
Mechanism of heart murmur formation. Two centuries of history have been studied
The sound of heart murmurs can be divided into two periods. The first period is
begins in 1819, when R. Laennec developed and introduced the method of aus-
cultivation. The second period dates back to the 30s of the current century and
associated with scientific and technological progress and the widespread use of tools
mental methods for studying the cardiovascular system. Leading
instrumental methods to study the genesis of noise can be considered a fo-
nocardiography. Diagnosis of heart lesions has made great strides forward.
with the introduction of echocardioscopy into practice.
Achievements of recent decades in the field of hydromechanics, acoustics
ki and cardiology allow us to schematically represent the basic mechanisms
involved in the formation of heart murmurs: morphological changes,
hemodynamic disorders and rheological disorders.
Usually the main prerequisite for the occurrence of heart murmurs
consider the corresponding anatomical changes that form in the process
process of ontogenesis or pathological process, which lead to tour-
blood bulence - the formation of vortex and tissue sound vibrations -
Unlike tones, noises are longer in nature,
since sound vibrations decay much more slowly. Most of
they consist of aperiodic sound vibrations. Depending on the
the predominance of certain frequencies can be roughly judged as low
or high frequency noise.
The intensity of the noise depends on the interaction of factors such as:
tube diameter, degree and configuration of narrowing, fluid flow rate
bones and viscosity.
The turbulent flow turbulence causes vibrations of the tube walls.
The higher the pressure gradient, the higher the frequency composition and loudness of the noise.
ma. The smaller the flow, the more low- and mid-frequency its composition -
Factors that contribute to the occurrence of murmurs in humans include:
1. Abnormally accelerated blood flow with normal or altered
heart valves and changes in blood viscosity.
2. The presence of antegrade blood flow through a narrowed or asymmetrical
new valve hole.
3. The appearance of retrograde (regurgitant) blood flow
a leaky valve (aortic valve insufficiency) or
septal defect.
In most healthy individuals, no murmur is heard, although close
There is always a turbulent flow in the night layer, but it is very pronounced
insignificantly, the blood flow is mostly laminar. Wall "vortex"
tions" have a low frequency and are not audible.
Causes of heart murmurs include:
1. Morphological factors
a) narrowing of valve openings
b) their deformation by affected valves, chordal filaments, plaques
c) valve defects
2. “Purely” hemodynamic factors
a) abnormal acceleration of blood flow with relatively unchanged
valve openings and normal diameter of large vessels
b) change in blood viscosity.
To the main morphological reasons contributing to the formation
noise should be attributed to ontogenetic, caused by the main possibilities
growth periods or developmental defects, and pathological associated
with a number of diseases (rheumatism, syphilis, sepsis, trauma, atherosclerosis).
Along with physiological changes associated with age-related
periods, malformations of the heart and blood vessels occur. Among them the most
septum, nonunion ductus arteriosus, narrowing of the aortic mouth
or pulmonary artery.
There are also various anomalies in the development of valves and linings.
panel apparatus. In the aorta and pulmonary artery there is a decrease or
an increase in the number of valves, additional atrioventricular valves are observed
cular valves. Frequently there is a perforation of the aortic valve and le-
pulmonary artery - small through holes of various shapes, on-
above the valve closure line. In addition to true tendon
threads, there are also false ones, which are attached not to the valves, but
go from the papillary muscles to the interventricular septum. False tendons
These filaments are found in both the ventricles and atria.
Damage to valvular and subvalvular structures by pathological
process (rheumatism, syphilis, atheromatosis, calcinosis) ends with an
tomic defect or defect, that is, there is destruction, smo-
schivaniya or sclerosis, fusion and thickening of their valves, deposition of fibril-
on, rupture or tear of the valve, tendon strands or papillary muscles,
which leads to intracardiac disorders of varying severity
or extracardiac hemodynamics, the formation of cardiac or vascular
noise Such changes most often affect the mitral, then the aortic
tal and, less commonly, tricuspid valve and pulmonary valve.
With hypertrophy and dilatation of the cavities of the heart, intra-serial
bowel hemodynamics and rheological properties of blood. In sharply expanded
mural thrombi form in the deep cavities of the heart, and may occur
and heart tumors, in particular myxomas, which also contribute to
changes in sound phenomena in the heart.
Sclerotic damage to the valves and fibrous rings of the openings of the de-
makes them rigid and inactive, which leads to insufficient smy-
valve flaps moving. Sometimes the valves thicken and curl toward
the walls of the aorta, as a result of which they cannot straighten and close -
xia - a slit-like defect is formed between them, through which blood flows
returns forcefully to the ventricle. No period of closed valves,
regardless of the location of valvular insufficiency, leads to the phenomenon
regurgitation or backflow of blood. Rheumatic or atheroma
severe sclerosis of cardiac structures can occur with deposition
lime in valve leaflets and thrombotic overlays during endocardial
tah. These deposits can protrude into the lumen of the cavities of the heart and blood vessels,
create roughness on valves and openings, contributing to the formation
reduction of cardiac and vascular murmurs.
Largest destructive changes valve apparatus are advancing
with subacute infective endocarditis.
Violation of the “law” is of great importance for the formation of noise.
correspondence of the cavities of the heart and blood vessels, when as a result of damage
myocardium, the walls of the aorta and pulmonary artery change spatially
but-volume and hemodynamic relationships between the atrium or
ventricle and the lumen of a large vessel.
Hemodynamic components. Ontogenetic and pathological
changes in the heart and blood vessels have a significant impact on intravascular
decimal hemodynamics. The main parameters of general hemodynamics include:
Xia percussion and minute volume , average systolic pressure, peripheral
resistance, arterial and venous pressure.
Intracardiac hemodynamics is characterized by arterial and ves-
nostril pressure, pulmonary pressure and big circle blood circulation (pulmonary veins - left atrium, vena cava - right atrium,
atrium - ventricle, and also ventricle - aorta or pulmonary artery),
residual blood volume, end systolic and diastolic
blood pressure in the atria, ventricles and large vessels. Inside-
cardiac hemodynamics is closely related to contractility
cardiac muscle, which forms the phase structure of systole and diasto-
In the presence of functional or organic valve or muscle
Noah insufficiency hemodynamic disturbances occur in certain
phases (systole or diastole) of the cardiac cycle. As a result, there is no
tviation of the period of closed valves in systole (in case of insufficiency of mit-
ral or tricuspid valve) or diastole (with insufficient
valve of the aorta or pulmonary artery) blood through the valve de-
the effect rushes towards lower pressure - a reverse current occurs
blood or phenomenon regurgitation.
Depending on the location of the valve lesion and the phase in which
reverse blood flow is formed, distinguish systolic and diastolic-
some regurgitation murmurs. They have a slightly different hemodynamic genesis
systolic ejection murmurs and diastolic or systolic stomach
daughter filling sounds.
Rheological components. Hemorheology is the science that studies
mechanical behavior of fluid, vessels and tissues in any parts of the system
blood circulation topics.
In relation to the circulatory system, rheology studies the inter-
related and interdependent changes in blood, heart structures and co-
vascular wall, occurring as a result of the influence of various forces,
acting on both blood and tissues of the cardiovascular system.
In the formation of intracardiac functional and organic noise
The decisive role belongs to the hemorheological component. Cro-
the flow or flow of blood is subject to a certain type of movement - laminar-
nomu, turbulent or Einsteinian.
If in the blood flow any element passes in a straight line and it
the move is parallel to the move of another similar element, then the flow is called
laminar or linear. If the fluid elements do not create linear
eddy currents are formed between them, then this type of flow is called
appears turbulent.
In addition to laminar and turbulent types of blood flow, there are
gravitationally stratified, or Einsteinian, type of blood flow.
The rheological properties of blood are diverse, however, only some of them
them plays a significant role in the genesis of functional and organic
noise, in particular the viscosity and physicochemical stability of blood,
hematocrit, velocity gradient and blood turbulence.
Noise classification. All heart murmurs are divided into two large ones
groups - organic noises arising from anatomical changes
holes and valve apparatus, and inorganic, based on
there are changes in the activity of the heart or the condition of its vessels, changes
changes in blood flow speed without anatomical defects. In each of these
groups include intracardial noises, that is, those arising inside the bands
those of the heart and large vessels extending from it, and extracardiac,
formed outside of these cavities.
TO intracardiacorganic noise refers to noise associated with
defeat of one or another anatomical structures inside the heart and large
vessels extending from it. Emit noise 1) casement, conditioned
damage to the valve leaflets, 2) chordal- in case of ruptures or shortening
chordal threads, 3) muscular- when the papillary muscles are weakened, 4) noises,
associated with the presence of pathological messages between the chambers of the heart and
large vessels, 5) noises, caused by obstacles or rough-
tami in the path of blood flow. This also includes relative noise-
valve accuracy due to expansion of the fibrous valve ring and
sounds of relative stenosis during expansion of the heart chambers and large blood vessels
vessels in relation to the normal valve opening.
TO extracardiacorganic noises include pericardial
And pleuropericardial friction noises and murmurs from compression of the aorta and lungs-
artery.
Inorganic murmurs are also divided into intracardiac murmurs
and extracardiac. TO intracardial noises include tachemic
(S.F. Oleinik), associated with an increase in blood flow speed, murmurs fi-
physiological, due to the developmental characteristics of the child’s heart,
noises anemic associated with a violation of physical and chemical properties
blood. TO extracardiac noises include vascular, arising in
vessels not directly leaving the heart. Noises cardiopulmo-
cash occur during cardiac systole and are associated with air filling
area of the lung located close to the heart.
According to its location, depending on the phases of cardiac activity,
All murmurs can be divided into systolic, diastolic and systolic
lo-diastolic. In all cases, phonocardiogram should be recorded.
a frame on which noise can be decreasing, increasing, diamond-shaped,
spindle-shaped, ribbon-shaped. There are low-, medium- and high-hour
loud noises.
Systole conditionally divided into 3 parts: beginning of systole or
protosystole, mid-systole or mesosystole, end of systole or mid-systole
lesistola.
During systole, 4 can be detected various options noise:
Early systolic, which is associated with 1 sound and occupies
1/2-1/3 part of systole;
Telesystolic or late systolic murmur ranks second
half of systole and adjacent to the 2nd tone;
neither with 1 nor 2 tone;
Pansystolic murmur occupies the entire systole, merging with the 1st and 2nd
Diastole is also conventionally divided into 3 parts: the beginning of diastole
ly or protodiastole, mid-diastole or mesodiastole and end of dia-
tola or presystole.
During diastole, 4 types of noise can be detected:
Protodiastolic murmur, which begins simultaneously with 2
Mesodiastolic begins at a certain interval after
2 tones and does not reach 1 tone;
Presystolic murmur is located at the end of diastole and adjacent
to 1 tone or diastolic murmur with presystolic amplification;
Pandiastolic, which occupies the entire diastole.
In a number of diseases - patent ductus arteriosus, arteriove-
nostril aneurysm, there is a systole-diastolic murmur.
Noise assessment. Noise assessment is carried out depending on the
at what phase of cardiac activity is it heard. The systolic murmur begins
sya with 1 tone or after it and ends before 2 tone or together with
him. Consequently, the main difference between systolic murmur and diastolic murmur is
The logical one is its location between the 1st and 2nd tone. If 1 tone is weakened,
linen and it is difficult to distinguish it from 2, then we must remember that 1 tone comes after
long pause and coincides with the apical impulse and pulsation on the carotid
Systolic murmurs occur more easily and are usually louder than
diastolic. Determine loud or quiet noise, what is its duration
activity, in what part of the systole it is located, what character
sit - increasing (crescendo) or decreasing (decrescendo), connected
whether it has 1 tone or there is an interval between the tone and noise, what is the timbre
dull color of noise - soft or blowing or vice versa - rough, scraping
sawing, sawing. To this day, the subjects have not lost their significance.
effective assessments of noise by clinicians. So, in his book "Sound
symptoms of acquired heart defects "I.A. Kassirsky writes how
therapists describe the nature of the noise: blowing, rough, whistling, humming
whining, howling, sawing, scraping, rumbling, hoarse, noise of a spinning wheel, sound
the flight of a bumblebee, the noise of a moving steam locomotive, the noise of a person having a rest at the steam train station
for (Botkin noise of a steam locomotive), tunnel, machine, hissing color-
flax iron immersed in water, the noise of a trill, a whining puppy, singing
young cockerel (V.F. Zelenin). You need to find out where it's going
noise, its prevalence and the area of maximum sound,
dependence on breathing phases, body position, physical activity.
When assessing diastolic murmur, indicate first of all at what
the diastole phase is it audible, that is, is it proto-diastolic,
mesodiastolic and presystolic. Then the noise is assessed according to those
the same parameters by which systolic murmur is assessed.
The place of best listening to noise is determined (punctum maxi-
mum) and conductivity.
In case of heart defects, organic systolic murmurs according to hemodynamics are
logical origin can be divided into ejection sounds(ostial stenosis
aorta or pulmonary artery) and regurgitation sounds- reverse current
blood (mitral or tricuspid valve insufficiency). Noise
ejection - systolic murmur of stenosis of the aorta or pulmonary trunk
is heard due to the fact that during the expulsion of blood from the ventricles
an obstacle arises in the path of blood flow - a narrowing of the vessel. Regulatory noises
gitation occurs due to the fact that during ventricular systole the blood
returns to the atria through an opening that is not completely covered, which
The swarm is a narrow gap.
In addition to the above listed heart defects, systolic murmurs can
be heard when the ductus arteriosus is patent, constituting the first
part of the systole-diastolic noise with this defect, with a defect between the
ventricular septum, with sclerosis and syphilitic lesions of the aorta,
with aortic aneurysm. The vast majority, almost all are functional
murmurs are systolic.
Diastolic murmurs are heard in aortic insufficiency
valve, with pulmonary valve insufficiency, left stenosis
atrioventricular orifice, stenosis of the right atrioventricular
openings, with patent ductus arteriosus, constituting the second
half of the systole-diastolic murmur.
With aortic valve insufficiency, protodiastolic murmur
associated with the reverse flow of blood under high pressure from the vessel into the stomach
daughters (protos - first).
Presystolic murmur is associated with increased pressure in the pulmonary circle
blood circulation and systole of the hypertrophied left atrium
(teles - end).
All diastolic murmurs are organic, excluding so-
There are only 3 noises.
Flint noise(A. Flint, 1812-1886, American physician) takes place
with aortic valve insufficiency. With this defect it is determined
organic diastolic murmur, in addition, reverse blood flow in the diastolic
tolu lifts the mitral valve leaflet and creates an artificial
mitral stenosis. The valve covers the left atrioventricular opening
hole, narrowing it, and blood in ventricular diastole comes from the left
atrium into the ventricle through a narrowed opening, resulting in high
The diastolic murmur is reduced.
Coombs noise(C.F. Coombs, 1879-1932, English doctor): in the beginning
attacks of rheumatism, swelling of the mitral orifice occurs, which causes
the appearance of diastolic murmur ( relative mesodiastolic murmur
mitral stenosis). As the condition improves, the noise may disappear
Graham Still noise(Graham Steell, 1851-1942, English doctor)
is characteristic of pronounced mitral defects, but it is determined above
pulmonary artery, since stagnation in the small circle causes stretching and
expansion of the pulmonary artery, or rather, its mouth, in connection with which it occurs
relative insufficiency of its valve.
With significant dilatation of the left atrium or left ventricle
relative mitral stenosis occurs, so it is possible that
protodiastolic murmur.
To listen to noise, use the same listening points as
when auscultating tones. It is necessary to listen to the patient in various
positions: standing, sitting, lying on your back, on your left side, if possible
the patient’s condition, then after physical activity (10 squats),
while holding your breath. The patient should take a deep breath, then exhale
no, at the same time the blood flow noticeably accelerates, therefore, creating
conditions for a more distinct appearance or change in the nature of noise.
Murmurs associated with aortic lesions are heard in a standing position,
when the hands are on the back of the head (Sirotinin-Kukoverov symptom).
The murmur is better heard at the site of auscultation of that valve or from -
version where it was formed. It can be carried out to other areas,
and noise travels better through the bloodstream . If the noise is well
peels off in 2 places, for example, at the apex and at the place of projection of the aor-
tal hole, and between them and on other holes much more is heard
weaker, this means that there are 2 different noises at two holes.
In this case, it is sometimes possible to note the difference in the nature of the noise at different
different holes: on one the noise is higher, on the other - lower, there - blowing, there
Scraping.
In addition, you should listen to the entire region of the heart, the axilla
cavity, interscapular space, vessels.
Let us briefly look at the characteristics of noise at the most common
wounded heart defects.
Mitral valve insufficiency
is caused by regurgitation of blood from the left ventricle into the left atrium during
systole time. Systolic murmur has a maximum sound at the top
hushka, can be long-lasting, occurs together with a weakened 1 tone or
is heard instead, during the entire systole. There is always noise at FKG
associated with 1 tone. May be harsh, rough or sawing in nature. So
as the expelling force of the heart decreases towards the end of systole, this noise weakens
occurs towards the end of systole (decrescendo).
The murmur may also be best heard at the insertion site 3
ribs to the sternum, where the left atrial appendage lies. It intensifies as
le load. The noise is well carried to the left armpit and little
changes with breathing. Can be heard better in the patient's position
left side (Lang maneuver). In addition to the above change in 1 tone,
often an accent of 2 tones is heard over the pulmonary artery.
The mechanism of occurrence of systolic murmur is similar when undershot-
tightness of the tricuspid valve: a stream of blood in the contraction phase
ventricles rushes from the right ventricle to the right atrium. Nedos-
leakage of the tricuspid valve can be organic or relative
telny. The maximum sound of systolic murmur for a given defect
will be at the base of the xiphoid process in the midline. When organizing
mental insufficiency, the noise is rougher, clearer, and with relative insufficiency -
softer, blowing.
Aortic stenosis. Characterized by the presence of systolic murmur,
the maximum sound of which is determined in the second intercostal space on the right
from the sternum, or on the manubrium of the sternum, and sometimes slightly lower - at
left edge of the sternum, at the insertion of the second and third ribs.
As a rule, this is one of the loudest and longest heart sounds.
mov. It is very sharp, rough, usually drowns out 1 tone and is heard
throughout systole. This noise belongs to the noise of expulsion and connection.
involved with the passage of blood through the narrowed opening during systolic
who empties the strongest part of the heart - the left ventricle. From
Of all known cardiac murmurs, it has the highest conductivity.
The noise is well carried out on the neck, on the back, especially under the crest of the right
scapula, can be heard along the spine. As a rule, at the same time
Systolic tremor is determined by palpation.
Organic systolic murmur at the aortic opening in addition to narrowing
the latter also occurs in connection with atheromatous changes in the mouth
aorta, which may not affect the width of the lumen of the vessel, but the blood flow
along the uneven bed is accompanied by noise, like the noise of a stream, flowing
walking along a rocky, uneven bed. The same noise is also heard
with luetic aortitis, which causes a sharp change in the wall of the aortic
you, as well as with aortic aneurysm.
The cause of systolic murmur may be a rather rare congenital
heart defect - narrowing of the pulmonary artery. Epicenter systole-
ical noise in these cases is usually detected in the second intercostal space
gap to the left of the sternum. The noise is carried out to the left clavicle and to the left
half the neck. Conduction to the area of the apex of the heart is less significant.
tel. The intensity of the noise can be sharp and even rude. In some
In cases 2, the tone is weakened or even absent. At the same time, with syphilis
tic lesions 2 tone is accentuated, has a metallic tint
Among other defects, in particular congenital ones, systolic murmur is high
peels off:
When the ductus arteriosus is patent, the noise produces an impression
surface noise, appearing as if directly under the ear of a high-
peeling. The epicenter of noise is determined in 3-4 intercostal spaces at some
distance from the sternum.
For ventricular septal defect (Tolochinov-Roger disease)
systolic murmur is determined by the passage of blood through a relatively
a small hole in the septum under high pressure from the left ventricle
daughter on the right. There is a very sharp, loud, prolonged noise, conductive
extending from the apex to the left edge of the sternum. The noise is characterized by
that during systole it does not increase or decrease, but retains its
intensity during the entire ventricular systole and is abruptly interrupted at
beginning of diastole. It can be heard more clearly in lying down position,
than in a standing or sitting position.
With a number of defects, as mentioned above, the noise can be diastolic
Aortic valve insufficiency. Hemodynamics of the defect character-
characterized by regurgitation of blood during diastole from the aorta back to the left
ventricle, since the valve does not cover the opening. At the same time, at all
valve openings 1 tone is weakened due to the lack of a period of closed
valves, 2nd tone is weakened, since there is damage to the valve itself.
The murmur begins immediately after the 2nd tone, in protodiastole, gradually decreasing
sounds towards the end of it (decrescendo noise), is better heard at the 5th point,
weaker - in the 2nd intercostal space to the right of the sternum. The noise is carried to the top
heart, sometimes heard along the left edge of the sternum. As was said
higher, in 25% of cases this murmur is carried to the apex of the heart and may
be mistaken for the murmur of mitral stenosis, but at the same time it has its own characteristics
thorny features. The noise is always decrescendo, hissing, pouring, soft,
sometimes long, sometimes short. I.A. Kassirsky points out that if
listen to the two-part rhythm and the “resting” second noise of the locomotive,
has just brought the train to the final station, then this is the sound
the perception will resemble auscultatory symptoms of the aortic
insufficiency. It is rarely loud, harsh, scraping or sawing.
shim. The noise is better heard when holding your breath after a deep breath.
It should be listened to in different positions of the patient, including
standing position, slightly bent forward. If the defect is syphilitic
what etiology, then due to the presence of syphilitic aortitis, diasto-
lic noise is heard more clearly in the 2nd intercostal space to the right of the chest
din, with the patient in an upright position. Often simultaneously with di-
Astolic murmur also determines systolic murmur due to the presence
at the same time, narrowing of the aorta. Moreover, as stated above, when
In this defect, additional noise may be heard - presystolic
loud Flint's noise, resulting from functional narrowing of the left
and with valve insufficiency, there is pronounced hypertrophy of the left
th ventricle. When its dilatation occurs, the so-called
the known “mitralization” of the defect, that is, the left atrioventricular
the hole expands so much that the unchanged mitral valves
the valve is not able to completely close this hole and comes back
relative insufficiency of the mitral valve, while auscultation
tive picture will be similar to a similar heart defect.
Stenosis of the left atrioventricular orifice. How isolated
the lesion is rare, more often combined with mitigation deficiency
ral valve. This makes it difficult for blood to pass through
from the left atrium to the left ventricle during diastole. At the same time,
The noise appears most often at the end of diastole, before systole of the left ventricle.
daughter, which is why it was called presystolic. Its origin
This is due to the acceleration of blood flow through the narrowed atrioventricular
hole during contraction of the hypertrophied left atrium.
The noise quickly increases, that is, it has a crescendo character, which distinguishes
it from protodiastolic murmur in aortic valve insufficiency
Pan, if this noise is carried to the top. The noise doesn't go anywhere
heard at the apex, better with the patient on the left side
(Lang's technique). The presence of presystolic murmur indicates sufficient
accurately preserved functional ability of the left atrium, while
same time in the presence of atrial fibrillation or atrial flutter, he
disappears. The noise increases with little physical activity, if
depends on the patient's condition. This noise, together with characteristic changes -
mi tones gives a typical melody of mitral stenosis: presystolic
noise followed by clapping 1 tone, systolic murmur due to
presence of mitral valve insufficiency at the same time, the click opens
digging of the mitral valve, that is, the "quail rhythm", as well as accent 2
tones on the pulmonary artery due to stagnation of blood in the pulmonary circulation
appeals.
As a casuistry, it should be noted that sometimes sound phenomena, analogous
similar to those heard in the heart with mitral stenosis,
may occur with myxoma of the left atrium. Diastolic murmur at
this disease is usually heard only with the patient sitting or
standing, and when moving to a lying position it disappears ("paradoxical
mitral stenosis "according to A.V. Vinogradov).
Thus, diagnostic value diastolic murmurs are significant
significantly greater than systolic, which, as already mentioned,
observed under a variety of factors: acceleration of blood flow, changes
changes in blood viscosity and papillary muscle tone.
In practice, it is very difficult to distinguish functional noise from
organic. Abroad, noise is called functional when relative
physical valve insufficiency, when the valve does not completely close
dilated hole due to its stretching due to weakness of the myocar-
Yes. In our country, the term "functional" is synonymous with inorganic
nic noise.
Inorganic (functional) noise, the causes of which
were listed above, are characterized by inconstancy and variability, their
the character is most often blowing, they depend on the phases of breathing, change in
depending on body position and stethoscope pressure. In the same time
organic noises are less dependent on these factors and differ
constancy, more rude.
The best place to listen to functional sounds is the base
heart, in particular above the trunk of the pulmonary artery in the 2nd intercostal space next
va, can be heard at the apex. At the same time, organic noise
are heard in different places depending on the topic of the lesion.
Functional noises are determined in a limited area and are characterized by
low conductivity. They are not accompanied by changes in tones or other
signs of damage to the valve apparatus. So, according to the clinic
V.Kh. Vasilenko, among 3000 healthy people aged 17-18 years, systolic
A murmur over the pulmonary artery occurs in almost 30% of cases. How
As a rule, inorganic murmurs are systolic murmurs, all diastolic murmurs are
ical noises, with very rare exceptions, are organic.
Inorganic noises are amplified in horizontal position pain-
leg and weaken in the vertical. With the elimination of the cause that caused them,
they may disappear. These noises diminish after exercise.
Extracardiac murmurs. Noises may occur due to movements
the heart and neighboring organs - the pericardium, pleura and lungs. Normally how much
The movement of the pericardial layers occurs almost silently. With inflammatory
state of the pericardium, a folded film is deposited on its surface
of fibrin, the surface becomes unsmooth, and friction of the visceral
and parietal leaves about each other is accompanied by noise, reminiscent
the crunch of snow underfoot or the kneading of fresh skin. When accumulating
exudate in the pericardial cavity, this noise disappears. It also decreases
with weakening of cardiac activity, with resorption of exudate or
his organization.
Pericardial murmur usually heard both during systole and di-
astole, somewhat intensifying with systole. It gives a clear impression that
that occurs very close to the examiner’s ear, intensifies with pressure
applying pressure with a stethoscope when the patient's torso is tilted forward. He Not
spreads through the bloodstream, variable in localization. Better listen
sewn in the area absolute stupidity hearts. The noise is heard when
uremia (“the death knell of uremics”), and it can be determined
even by palpation. Pericardial friction noise is observed in myocardial infarction.
and was first described by Kernig with pericarditis epistenocardiaca.
The occurrence of noise is due to the fact that the area of necrosis in the mi-
ocarde calls inflammatory processes in the adjacent part of the epicardium.
A pericardial friction rub in these cases is sometimes heard during
days, and sometimes disappears after a few hours.
Pleuropericardial murmurs occur in the hours adjacent to the heart
in the lungs, expanding during systole due to a decrease
heart volume. Air, penetrating into these parts of the lungs, gives noise to the vesicle -
polar in nature and systolic in time.
The lecture on vascular research presents in detail the places
listening to arteries. Let us recall that when auscultation of arteries, located
located far from the heart, for example, on the femoral artery, the tones are not high-
are heard, and only sometimes as a result of a sharp tension in the artery
1 tone is peeling off.
In case of aortic valve insufficiency, 2nd tone in the carotid arteries
and the subclavian artery may be weakened or absent. Extremely edited
However, with this defect, two tones are heard on the femoral artery (double
Traube's tone), the appearance of which is explained by a sharp vibration of the wall
arteries during systole and diastole.
If the artery is slightly compressed with a stethoscope, healthy person
You can listen to a noise due to the passage of blood through the narrowed pros-
Vessel Vet. In case of aortic valve insufficiency on the femoral artery,
when you lightly compress it, you can hear two noises, the stronger one -
during systole and less pronounced - in ventricular diastole (double
Vinogradov-Durozier noise).
For anemia on jugular vein sometimes a blowing or buzzing sound is heard
a pressing noise (“spinning top noise”) that intensifies with deep inspiration.
CHARACTERISTICS OF HEART NOISE IN SOME ACQUIRED
AND CONGENITAL HEART DEFECTS
HEART DEFECTS Phasing Epi-Hemodyne-Continuation-Zone Techniques, Characteristics-
and the form of the center of the mcical inhabitants - pro- facilitated - teris-
noise feature leading potika
the phenomenon of tones
INSUFFICIENCY - systole - superior - regurgi - pansis - left lying by 1 tone
NESS MIT- schatational toliche- subarm- pain- weakened-
RALNOGO decreasing - cervical ku with flax, 2
VALVE has a delayed tone on
there is a respiratory tract infection
nova- at the phase of new ar-
nie se-exhalation teria
heart, accent
on the left is tuiro-
from gro-van,
Dina 3 tone
STENOSIS OF THE LEFT diastole-upper-ejection murmur-proto-not pro-on the left rhythm
ATRIO-VENTRIC shkanija (ste- diasto- leads - side and quail
CULAR FROM- increasing- notiches- after
VERSTATION cue, physical
meso-, skoe
presi- load-
capitals
INSUFFICIENCY - diastole - 2 inter-regurgi - proto-vertical point - 1 and 2
AORTA-chesky rebeta-meso-Botcal tone
LINEN CLA- decreasing diaston-Er- position- weakened
PANA on the right lices- ba and nie or lena
from the top - sitting, on -
Dina's head bowing
NARROWING of systole - 2 intersteno-pansonary to right - 1 and 2
MOUTH chelic rebetic- or th- and under- root side tone
AORTA - rhomborean salmon - keys - with retardation - weakened -
Visible on the right
from Greek artechania to
Diny rii, me-exhale
INSUFFICIENCY - systole - at the main-regur - pansis - not pro- at the height - 1 tone at
THREE- CHICAL vania gita- toli- leads- those in- fundamentally
VALVED tape-meschevi-tsionny Xia ha with knowledge of me-
VALVE visible bottom support obvious
or the process of breathing th otro-
decrease - decrease -
ying lablen,
pulmonary
NOISE RECOGNITION ALGORITHM
Stage 1 characterization of heart sounds
Stage 2 noise identification
Stage 3: clarification of the noise to phase ratio
cardiac activity
systolic
diastolic
systole-diastolic
Note: clarify the main distinctive features
signs of the specified noises (graphically),
emphasize that systole-diastolic
noise occurs only if the
same direction of blood flow
both in systole and in diastole, therefore true
systole-diastolic murmur can only be
vascular origin, for example, open
ductus arteriosus, because in the chambers of the heart
such a condition cannot be met.
Stage 4: clarification of the noise epicenter (punctum maximum)
Stage 5 duration of noise and its connection with tones
early systolic and protodiastolic
("early" noises)
late systolic and telediastolic
(presystolic)
mesodiastolic, mesodiastolic with
pansystolic and pandiastolic
Note: emphasize the difference between "holo" and "pan"
noises ("pan" noises are associated with tones)
Stage 6: clarification of the noise shape
increasing - crescendo diamond-shaped
waning - decrescendo fusiform
ribbon-like
Note: you can indicate the dependence of the “shape” of noise on hemo-
dynamic factors, for example, pressure gradient
between the aorta and the left ventricle or vice versa
mouth left ventricle and aorta with aortic
Stage 7: finding out the timbre of the noise and its volume
soft rough
blowing scraping
Note: give examples of comparisons of noise timbre with noise
"overspilling of sand" (mitral insufficiency)
valve), “rolling” or “roaring” with miter-
flax stenosis
Stage 8 identification of the noise zone
left axillary region
base of the heart
interscapular space
abdominal aorta
Stage 9 murmur type according to hemodynamic mechanism
expulsion noise
regurgitation noise
Stage 10 features changes in noise intensity in
depending on body position, physical
loads, etc., while showing the possibility
distinction between organic and inorganic
functional noise
Stage 11: differentiation of organic noise from
functional
Note: indicate the main features of organic
noise: parallel change in tones, pro-
management, strengthening after physical activity and
emphasize that based on the conducted
algorithm can be reliably delimited by the organi-
functional noise
Stage 12: differentiation of intracardial noise from
extracardiac
Note: dwell on the distinction between pericardial,
pleuropericardial and cardiopulmonary murmurs
Stage 13 identification (establishment) of a certain symptom-
complex
Note: it is advisable to give an example of "work"
algorithm, emphasizing that the doctor comes to the diagnosis from the priz-
to the symptom complex, and not vice versa.
Demonstrate, for example, the diagnosis of deficiency
mitral valve, starting from the characteristics of sounds:
weakening of 1 tone, emphasis and bifurcation of 2 tones
pulmonary artery, 3rd tone at the apex, until a murmur is detected
maximum at the top, and so on at all stages.
Then talk about the symptom complexes of deficiency
mitral valve, stenosis of the left atrioventricular
th hole, aortic heart defects, congenital
heart defects, paying attention to hemodynamic
mechanisms and characterize the noise, adhering to
the specified algorithm.
When constructing the contact network (CN) of electrified railways, overhead lines (OHL) on CS supports and on independent supports, the following are used as the main electrical insulating material: porcelain, glass and polymers with high electrical insulating properties, electrical and mechanical strength, etc.
Electrical insulators and structures made from them are independent electrical insulating structures used in switchgears, power lines or various kinds electrical installations, as well as being part of many electrical apparatus. In all cases, electrical insulating structures and insulators perform, basically, very specific functions: with their help, mechanical fastening of current-carrying parts is carried out, their necessary relative position and the invariance of electrical parameters are ensured: circuit inductance, characteristic impedance of the conductor, etc. Electrical insulating structures and insulators, in addition, must withstand, without breakdown or flashover, possible atmospheric lightning and internal switching overvoltages in operation.
The most common materials used for the manufacture of electrical insulating structures and insulators are electrical porcelain and glass, which is due to the availability of raw materials, fairly well-mastered production technology, and the relatively high level of their electrical properties. Behind last years Electrical insulation production began to widely use ceramic and glass products with improved electromechanical and thermal characteristics: high-alumina porcelain, corundum, ultraporcelain of various modifications, heat-resistant and capacitor ceramics and other types of electrical ceramics.
One of the promising areas of technical progress in railway transport in the field of creating reliable electrical equipment for the generation, transmission and distribution of electrical energy from compressor stations and overhead lines is the use of polymer materials. In many cases, the use of polymer materials opens up relatively simple and inexpensive ways to improve technical means that contribute to solving most important tasks to increase the volume of transportation work, weight and speed of trains. The causes of overvoltages in power supply devices can be atmospheric discharges, switching processes, as well as certain operational conditions of electrical equipment.
To protect equipment, there are methods for protecting electrical insulation from atmospheric and switching overvoltages, devices, protection devices and circuit solutions aimed at increasing the service life of the insulation.
Despite the relatively low cost of insulation in electrical machines, transformers and other equipment, when it breaks down, unexpected funds are spent, emergency operating modes are created and, as a consequence, railways suffer losses due to locomotive downtime on the lines and during repairs at the depot. At the same time, it takes a lot of time to disassemble, repair, dry and assemble electrical machines.
Under operating conditions, the insulation is constantly exposed to long-term operating voltage and periodic exposure to atmospheric and switching overvoltages, exposure to high and low temperatures, especially sudden temperature changes, shaking, vibration, pollution, including aggressive substances. It is quite natural that over time the dielectric properties of electrical insulation deteriorate, the insulation ages, its mechanical strength decreases and, most importantly, its electrical strength decreases. Eventually it may drop so low that breakdown occurs even at operating voltage.
Therefore, under operating conditions, it is necessary to periodically monitor the insulation characteristics, timely carry out preventive measures aimed at maintaining the characteristics within the established standards, organize repairs and replace defective insulation even before it is broken during operation.
