Dynamic Auscultation
Listening to the change in character,
behaviour and the intensity of the
heart sounds and murmurs to
physiological and pharmacological
maneuvers…….
“AUSCULTATE WITH ALTERED HEMODYNAMICS”
Dynamic Auscultation
• Source of murmur : Right Heart ~ Left Heart
• Differentiate closely simulating murmurs
Outflow ~ Regurgitatnt murmur
• Differentiate flow murmurs from those of
structural deformity : Austin Flint ~ MS
• Differentiate Dynamic from Fixed Obstructions
Maneuvres
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PHYSI(OLOGI)CAL
Postural change
Supine / L Lateral
Standing
Squatting
Valsalva
Handgrip
Cycle length change
PHARMACOLOGICAL
• Amyl nitrite
• Phenylephrine
Position
• Left lateral decubitus : Augments the murmur of
MS, MR, Austin Flint, MVP & S1, LV S3 & S4
• Sitting & Leaning forward : ↑ AR murmur
• Sitting with arms raised above the head : ↑ AR
• Knee chest position : AR, Pericardial Rub
• Passive leg raising : ↑ VR >↑ Right Heart events
Respiration
• Inspiration augments right sided events, as the
venous return increases :
TR & TS , PR & PS murmurs ; RV S3,S4 & TV OS
S1 & S2 split widen.
• Exception is PES – augmented in expiration
# Preferably quiet respiration
# Avoid apnea
# Listen the first few beats
# In erect posture if Venous pressure is high
Carvallo’s sign
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Inspiratory accentuation of TR murmur
Early systolic murmur > holosystolic
Blowing quality > musical
Absent in severe RV failure
associated TS is severe
• If venous pressure is very high,
listening in upright posture may help
Reversed Carvallo sign
HCM with RVO obstruction - ? ↑ VR > widened RVO
Respiration
• Left sided events are better heard in expiration
MR, MS, AS & AR murmurs
LV S3 & S4, Mitral OS
Click & murmur of MVP occur later
@ PV – LA gradient increases > ↑ LV filling
@ Lung overlap decreases
@ Apnea for faint AR murmur
Pms = mean systemic pressure; Ppc = pulmonary capillary hydrostatic pressure; Ppi =
pulmonary interstitial hydrostatic pressure; Ptm = pulmonary capillary transmural pressure
Abrupt standing
• S2 split which may be wide, may narrow down ,
while the fixed split may persist
• A2 OS interval widens – differentiates from
wide split of S2
• All murmurs ( except MVP/HOCM) decrease
• ESM of HOCM becomes louder and longer
• Click occurs earlier, murmur becomes longer in
MVP – loudness shows variable response
Isometric Hand Grip
HAND DYNAMOMETER
Physiological changes
of
ISOMETRIC
HANDGRIP
EXERCISE
Isometric Hand Grip
LV S3 & S4 get augmented
Murmurs of MR,AR,VSD intensify
Mitral stenotic murmur may augment
Systolic murmur of HOCM may diminish
Click & late sytolic murmur of MVP get delayed
Transient Arterial Occlusion
Squatting
• Increased venous return and
CO > augments most murmurs
atleast initially (AS,PS,MR,AR,VSD)
Right heart murmurs do so
earlier
• Increased ventricular volume >
murmur of HOCM ↓
murmur of MVP ↓→
• Ejection murmur of TOF ↑
P Hanson
Br HeartJ7 1995;74:154
Central Aortic Pressure
T Murakami
AHJ 2002; 15:986–988
Hemodynamics of Squatting
T Murakami AHJ 2002; 15:986–988
T Murakami
AHJ 2002; 15:986–988
Valsalva Maneuver
Decreased venous return & CO, HR ↑; PP↓
S2 split narrows down, S3 & S4 diminish
Valsalva Maneuver
• Reduces the intensity of all murmurs
except that of HOCM & MVP
• Murmur of HOCM intensifies as the LV
cavity size decreases
• Click occurs earlier, the murmur
lengthens in MVP – may not intensify
• During release, the intensity of right
heart murmurs returns earlier - 1 to 3
vs 5 beats for left heart murmurs
VALSALVA STRAIN
ASD, HF, MS
Cycle Length Variation
Post premature beat / Long cycle short cycle of AF
• Post VPD / Long > Short cycle of AF :
Outflow murmurs ( AS/PS) accentuate
Regurgitant murmurs do not change
Aortic Stenosis
HOCM
Amylnitrite Inhalation
 < 30 secs : Systemic vasodilatation
 30 – 60 secs : ↑ HR & CO
 Augments S1, LV S3 & S4, TV & MV OS,
murmurs of AS,PS,TR & HOCM
 A2 – OS may widen
 Diminishes the murmurs of MR, AR, VSD,
PDA & Systemic AVF
 Click & Murmur of MVP occur earlier
Amyl Nitrite Inhalation
Augments
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Diminishes
Aortic stenosis
Mitral regurgitation
Pulmonary stenosis
TOF
Tricuspid regurgitation Mitral regurgitation
Mitral stenosis
Austin Flint
Pulmonary regurgitation Aortic Regurgitaation
Phenylephrine
↑ BP & SVR ↓ CO & HR – last for 3-5mts
• Reduces intensity of S1, A2-OS may widen
• Augments the murmurs of VSD, PDA, MR, AR,
TOF, Systemic AVF
• Diminishes AS, MS & functional murmurs
• ESM of HOCM diminishes
• Click & murmur of MVP get delayed
↑Afterload,↑Preload,↓Contractility
↓Afterload,↓Preload,↑Contractility
Valslava
the caveats are………
• Avoid dynamic auscultation in sick patients
• When postures are changed, transition
should be abrupt
• Continuous auscultation is required, when
maneuvres are being elicited
• Concentrate on the first few cycles after
maneuvres
• Realize that each maneuvre induces more
than one alterations in hemodynamics