Soplos y sonidos

Cardiacos
Francisco Albornoz, MD, MSCI.

Semiologia I. UCSC.2004
Las valvulas cardiacas se clasifican en:
- Auriculoventriculares: Mitral y tricuspide.
- Semilunares: Aortica y pulmonar.

Durante el sistole las valvulas semilunares se abren y las

auriculoventriculares se cierran.
En diastole ocurre lo opuesto: Las valvulas auriculoventriculares se abren
permitiendo el llene ventricular y las semilunares se cierran para prevenir el
retorno sanguineo desde la circulacion sistemica y pulmonar.
 En individuos normales estas valvulas funcionan normalmente.

En estados patologicos se produce :

• Estenosis (estrechez)
• Insuficiencia (regurgitacion)
• Combinacion de ambas (enfermedad)

Debido a que las valvulas semilunares y auriculoventriculares funcionan

en forma opuesta en el ciclo cardiaco, los efectos de estenosis o
insuficiencia son diferentes.
Soplos sistolicos: Estenosis aortica, estenosis pulmonar, insuficiencia
mitral, insuficiencia tricuspidea.
Soplos diastolicos: Estenosis mitral, estenosis tricuspidea, insuficiencia
aortica e insuficiencia pulmonar.
Recordar Clasificacion

Soplos:
 Sistolicos: Estenosis Aortica, Estenosis
pulmonar, insuficiencia mitral, insuficiencia
tricuspidea.

 Diastolicos:Insuficiencia aortica, insuficiencia

pulmonar, estenosis mitral,
estenosis tricuspidea.
Sitios auscultatorios
 En el corazon normal hay 2 sonidos cardiacos fundamentales:
"lub dub“.

El "lub" es el primer ruido (S1):

Causado por la turbulencia del cierre de la valvula mitral y tricuspidea
al comienzo del sistole.

El "dub" es el segundo ruido (S2):

Causado por el cierre de las valvulas aortica y pulmonar marcando el
fin del sistole.

De esta manera el tiempo entre el primer ruido y el segundo ruido

define el sistole ventricular.

El tiempo entre el segundo ruido y el primer ruido define el diastole

ventricular (llenado ventricular).
Registro del primer y segundo ruidos cardiacos.
Existe tambien un tercer y cuarto ruido (S3 and S4).
Estos ruidos pueden ocurrir en personas normales o
asociarse a condiciones patologicas. Debido a la cadencia
ritmica S3 y S4 son llamados galopes.

Los galopes son ruidos de baja frecuencia asociados con

el llene ventricular (diastole).
El galope asociado con el llene ventricular temprano es S3 y puede
ser oido en condiciones patologicas como sobrecarga de volumen y/o
disfuncion ventricular.

El galope asociado con el llene ventricular tardio es S4 y puede ser

escuchado en condiciones como hipertension no controlada.
Los soplos son causados por turbulencias en los vasos y camaras
cardiacas.

Flujo incrementado a traves de una

estructura normal: Anemia- soplo
aortico sistolico.

Estenosis causa turbulencia por obstruccion

Al flujo. Ej: estenosis mitral y aorticas.

El flujo desde una zona estrecha a una

Dilatada puede causar trubulencia. Ej. Aorta
Dilatada con valvula aortica normal.
Los soplos son causados por turbulencias en los vasos
y camaras cardiacas.

Una membrana que vibra con el flujo

De sangre puede causar turbulencia:
Ej. Ruptura de un musculo papilar.

Flujo desde una camara de alta presion

A una de baja presion: ej. Comunicacion
Interventricular.
Los soplos tambien pueden clasificarse de acuerdo a su forma

Decrescendo : El soplo comienza a alta intensidad y

Termina a baja intensidad. Caracteristico
De insuficiencia aortica y pulmonar. En general
ocurre cuando una Valvula no cierra apropiadamente.

Crescendo/Decrescendo : Comienza a baja intensidad y

luego incrementa. Es caracteristico de los soplos sistolicos
causados por estenosis.Ej. Estenosis aortica y pulmonar.Son
tambien llamados soplos en diamante o de eyeccion.

Holosistolico/pansistolico : De intensidad uniforme a traves

del sistole. Ej insuficiencia mitral.
Los soplos tambien pueden clasificarse de acuerdo a su intensidad:

Los soplos sistolicos son clasificados en escala del 1 al 6.

Grado 1: Apenas audible.

Grade 6: audibles sin dificultad alguna con el estetoscopio
aplicado suavemente en el torax.

Los soplos Diastolicos son clasificados del 1 al 4.

 Mecanismo de los soplos: Ciclo Normal

Normal Diastole
- Atrioventricular valves (tricuspid and mitral) are open.
- Semilunar valves (pulmonic and aortic) are closed.

Normal Sistole
- Atrioventricular valves (tricuspid and mitral) are closed.
- Semilunar valves (pulmonic and aortic) are open.
 Aortic Valve Murmurs

Aortic Insufficiency
- Turbulence caused by the backflow
of blood as the valve is partially open.

Aortic Stenosis, Aortic Sclerosis, LV Flow Obstruction

- Turbulence caused by the flow of blood through a
narrowed valve.
- Murmur radiates to carotids.
 Pulmonic Valve Murmurs

Pulmonic Regurgitation
- Turbulence caused by the backflow
of blood as the valve is partially open.
- Heard along left sternal border.

Pulmonic Stenosis
- Turbulence caused by the flow of blood
through a narrowed valve.
 Tricuspid Valve Murmurs

Tricuspid Stenosis
- Turbulence caused by the flow
of blood through a narrowed valve.

Regurgitation
- Turbulence caused by the backflow
of blood into the right atrium because
of the failure of the valve to close properly.
- May radiate to the apex via papillary muscles.
 Mitral Valve Murmurs

Mitral Stenosis
- Turbulence caused by the flow of
blood through a narrowed valve.

Mitral Regurgitation
- Backflow of blood into the left atrium
over an abnormal mitral valve is
associated with a systolic murmur.
- May radiate to axilla.
 Atrial and Ventricular Septal Defects

Atrial Septal Defect

- Systolic murmur is due to increased
blood flow through the pulmonic outflow tract.
- Mid-diastolic rumble is due to increased
blood flow through tricuspid valve.

Ventricular Septal Defect

- Flow of blood from higher pressure chamber
(left ventricle) to the lower pressure chamber
(right ventricle) causes a systolic murmur.
- Murmur is usually holosystolic.
 Patent Ductus Arteriosus

Patent Ductus Arteriosus

- A continual connection between the
aorta and pulmonary artery causes a
pressure differential resulting in a
continuous turbulence causing a
diastolic murmur.

Patent Ductus Arteriosus

- A continual connection between the aorta
and pulmonary artery causes a pressure
differential resulting in a continuous
turbulence causing a systolic murmur.
 Aortic Stenosis
Aortic Area Murmur
[2nd Intercostal space on the right]
Systolic

Crescendo-decrescendo murmur [may vary depending on the degree of stenosis].

Associated with delayed peaking and upstroke of the carotid pulses [pulsus “Parvus
et Tardus"]. This may not necessarily hold true for the elderly.
Decreases in intensity with a Valsalva maneuver. Increases in intensity with
squatting. Radiates to the carotids.
May radiate to the mitral area - (Gallavardin phenomenon); this may especially
hold true in the elderly: in this setting, the murmur may be mistaken for mitral
regurgitation.
As stenosis worsens, peak of the murmur becomes later in systole and murmur
invades A2 of the second heart sound; 2nd sound may become paradoxically
split.
The aortic valve may become fixed in a narrowly opened position producing both
aortic stenosis and aortic regurgitation.
Causes largely are calcific [majority of cases], rheumatic deformity and or
congenital abnormality of the valve [seen in the young <than age 30].
Has a male predominance 4:1 and occurs in 1-2 % of the population.
In younger patients may be associated with ejection click.
Aortic Valve - Normal

Aortic Stenosis - Mild

Aortic Stenosis - Advanced

Calcified Aortic Stenosis

and/or Sclerosis

Bicuspid Aortic Valve

(non stenosed)
Bicuspid Aortic Stenosis
 Aortic Sclerosis
Aortic Area Murmur
[2nd Intercostal space on the right]
Systolic

May mimic aortic stenosis but is not associated with

significant stenosis.
Is secondary to calcific deposits of the aortic annulus with or
without invasion onto the leaflets themselves.
Usually does not invade the second heart sound.
May be associated with aortic insufficiency.
Most commonly found in the elderly population.
 Patent Ductus Arteriousus
Aortic Area Murmur
[2nd Intercostal space on the right]
Systolic

May be silent when small.

Moderately small to large lesions give a continuous (systolic
and diastolic) murmur heard throughout the precordium.
Large lesions associated with a wide pulse pressure.
If severe pulmonary HTN occurs, Eisenmenger’s physiology
may be present with disappearance of the murmur and
differential cyanosis.
Normal

Patent Ductus Arteriousus

 Left Ventricular Outflow Tract Obstruction
(Hypertrophic Obstructive Cardiomyopathy)
Aortic Area Murmur
[2nd Intercostal space on the right]
Systolic

Systolic ejection murmur is caused by marked turbulence of blood flow as it

accelerates past the partial obstruction in the outflow tract. The obstruction can
be either supravalvular or subvalvular. These are also referred to as
supravalvular and subvalvular aortic stenosis, respectively.
Supravalvular:
•Can be part of “Williams” syndrome.
•Patients with Williams’s syndrome have elfin facies, ejection murmurs without
a click, no aortic regurgitations and right arm BPs and carotid impulses are
stronger than the left.
Subvalvular:
•Usually a discrete muscular ridge with ejection murmur and aortic insufficiency
Normal

Left Ventricle Outflow Tract Obstruction

 Aortic Insufficiency
Aortic Area Murmur
[2nd Intercostal space on the right]
Diastolic

May be acute or chronic.

Usually decrescendo diastolic murmur with or without a systolic ejection
murmur heard at aortic area and along left sternal border.
Pitch may vary depending on chronicity.
Causes include aortic root dilation [Marfan's or HTN], aortic aneurysm,
dissection, syphilis, inflammation of root [Ankylosing Spondylitis], rheumatic
valve disease, valvular calcification, endocarditis, trauma.
Chronic and severe cases associated with wide pulse pressure, rapid and
forceful carotid upstrokes with dramatic collapse (Corrigan’s pulse), Head
bobbing with each systole (Demusset’s sign), prominent pulsation of skin
capillaries (Quinke’s pulse), Hill’s sign (higher popliteal than brachial artery
pressure), Duroziez murmur (to and fro murmur heard over the femoral artery).
S3 or S4 may be present.
 Mechanical Heart Valves

The sounds generated by mechanical valves are as varied as the different

designs of artificial valves that are available.
The sounds may be relatively indistinguishable from the normal sounds as is the
case with a bioprosthetic valve or may be quite unusual as is the case with
certain mechanical valves. For example, a porcine or homograft valve may
sound the same as its normal counterpart located in the same position within the
heart.
An older model mechanical valve such as the Starr Edwards valve may be
associated with a popping sound accompanied by loud systolic and occasionally
diastolic murmurs. Newer mechanical valves consisting of a single tilting disc or
two discs may have metallic opening and closing sounds accompanied by
murmurs and or clicks. Therefore, there is no one characteristic group of sounds
that characterize artificial heart valves.
 Pulmonic Stenosis
Pulmonic Area Murmur
[2nd Intercostal space on the left]
Systolic

May be supravalvular (usually associated with other congenital anomalies, i.e.:

Tetralogy, Noonan’s syndrome, etc.), valvular (almost always congenital),
or subvalvular (usually seen in association with a ventricular septal defect).
Crescendo-decrescendo murmur is the loudest in this area.
May be associated with other murmurs common to associated congenital
cardiac abnormalities.
Murmur may be low, medium or high pitched, dependent on the severity of the
gradient (moderate greater than 50 mm Hg gradient, severe greater than 80
mm Hg gradient); the later the peak of the murmur, the higher the gradient.
Usually associated with a pulmonary ejection click.
Murmur increases in intensity with inspiration.
Pulmonic Valve - Normal

Pulmonic Stenosis - Mild

Pulmonic Stenosis
- Advanced

Bicuspid Pulmonic
Valve
(non stenosed)
 Atrial Septal Defect
Pulmonic Area Murmur
[2nd Intercostal space on the left]
Systolic and Diastolic

• Associated with systolic murmur due to increased flow through the

pulmonic outflow tract.
• Associated with a fixed split S2.
• In large atrial septal defect may be associated with a mid-diastolic rumble
due to increased blood flow through tricuspid valve. Mid-diastolic rumble is
best heard at the tricuspid site.
 Pulmonic Regurgitation
Pulmonic Area murmurs
[2nd Intercostal space on the left]
Diastolic

• Decrescendo low pitched murmur - loudest in pulmonic area and along

left sternal border.
• Usually well tolerated except in severe cases, which over time may lead
to right ventricular failure.
• Almost always associated with congenital abnormalities, pulmonary hypertension,
endocarditis or carcinoid heart disease.
• May occur postoperatively after repair of Tetralogy of Fallot.
 Innocent Flow Murmur
Pulmonic Area Murmur
[2nd Intercostal space on the left]
Systolic

• This murmur is often heard in young healthy individuals.

• It is most commonly noted in children, adolescents, and pregnant women.
• Soft early to mid-systolic murmur.
• It is believed to be a generated by turbulent flow through a compliant pulmonary
and/or aortic outflow tract initiated by the powerful contraction of a young healthy
right ventricle.
• The murmur is louder in thin chest individuals than in muscular or fat people.
• The murmur may be quite loud depending on hydration status.
• May change in intensity with inspiration and expiration.
• May be associated with normal S2 splitting.
• It often dissipates with age.
 Tricuspid Stenosis
Tricuspid Area Murmur
[4th Intercostal space on the left]
Diastolic

•Largely seen with rheumatic heart disease, Carcinoid heart disease or Phen-fen.
•Almost always seen associated with mitral stenosis.
•Right side diastolic rumble that changes with respiration.
•May be associated with right sided S3.
•Large jugular venus pulsations are usually present (prominent A wave if present).
•May be associated with accompanying tricuspid regurgitation murmur.
Tricuspid Valve - Normal

Tricuspid Stenosis - Mild

Tricuspid Stenosis - Advanced

 Tricuspid Regurgitation
Tricuspid Area Murmur
[4th Intercostal space on the left]
Systolic

• May be secondary to pulmonary hypertension or primarily due to

valvular abnormalities.
• Holosystolic or ejection type murmur loudest in this area; may radiate to the apex.
• Murmur changes with respirations.
• Elevated jugular venous pulse with prominent V wave.
• May be associated with pulsatile liver and marked edema in severe cases.
Tricuspid Valve - Normal

Mild Scarring

Advanced Scarring

Leaflet Elongation

Papillary Muscle Rupture

 Ventricular Septal Defect
Tricuspid Area Murmur
[4th Intercostal space on the left]
Systolic

• Pitch and intensity may vary depending on the size of the defect
and the pressure differential across the septum.
• Usually holosystolic, may be ejection type in character.
• May be associated with other murmurs, i.e.:
mitral regurgitation, aortic insufficiency etc.
depending upon other co-dominant abnormalities.
• Usually congenital in origin, may be acquired in the face of myocardial infarction
(usually inferior but may be seen in anterior as well).
• Murmur may disappear if Eisenmenger’s physiology becomes present.
 Mitral Stenosis
Mitral Area Murmur
[Apex]
Diastolic

• Most commonly seen in rheumatic heart disease.

• May be congenital [much less common] other causes:
cardiac tumors, mucopolysaccharidoses, Carcinoid,
Endomyocardial Fibroelastosis.
• Opening snap usually present. Distance between opening snap and S2
decreases as severity of stenosis increases.
• Usually associated with a low-pitched diastolic rumble.
• May be associated with a systolic murmur as well.
• P2 may be palpable.
• Right ventricular lift may be present.
• S1 often accentuated.
• Prominent Jugular vein A waves (when in sinus rhythm).
• Edema and liver engorgement present in severe cases.
Mitral Valve - Normal

Mitral Stenosis - Mild

Mitral Stenosis - Advanced

 Mitral Regurgitation
Mitral Area Murmur
[Apex]
Systolic

• Etiologies include rheumatic fever, endocarditis, papillary muscle

dysfunction, ruptured chordae tendinae, myxomatous degeneration of the
mitral valve, mitral annular calcification, atrial myxoma, collagen vascular
disease (i.e.: lupus).
• Murmur may be early, mid, or late ejection type or holosystolic with radiation
to the axilla.
• In compensated cases, apical impulse is hyperdynamic.
• In decompensated cases, apical impulse is displaced laterally and
downward.
• Associated with S3 and diastolic rumble in severe cases.
• May cause secondary pulmonary hypertension with liver congestion,
tricuspid regurgitation and edema.
Mitral Valve - Normal

Mild Scarring

Advanced Scarring

Leaflet Elongation

Papillary Muscle Rupture

 Mitral Valve Prolapse
Mitral Area Murmur
[Apex]
Systolic

• The mitral valve is a two leaflet valve separating the left atrium and left ventricle.
In the majority of individuals the two leaflets are of relatively equal length and
closure does not allow for significant regurgitation or abnormal movement.
• Individuals with prolapse have increased connective tissue and/or
mucopolysaccharide deposition in one or both leaflets resulting in abnormal
coaptation and/or “bowing” of the leaflets during ventricular systole. This may
result in a host of extra systolic sounds including systolic clicks, mitral
regurgitation of various grades or a combination of the above.
Affects 2% to 6% of the population.
• In some cases, patients may be associated with other valvular malformations,
autonomic nervous system abnormalities, chest pain, a tendency towards atrial
or ventricular arrhythmias, and migraine headaches. This constellation of
symptoms has been coined as “the mitral valve prolapse syndrome”.
• Many patients with this syndrome may find some relief of symptoms with the use

of beta blockers.
• In Chile the most common cause is rheumatic disease.
Mitral Valve - Normal

Leaflet Elongation

Papillary Muscle Rupture

Normal

Ventricular Septal Defect