Maneuvers
How maneuvers affect murmurs
Venous return (input)
Blood making it into right atrium
More coming in means more can go out...
less coming in means less can go out...
Constricting veins ➔ ↑ venous resistance ➔ ↓ venous return
Denominator goes to 2
BUT with sympathetic stimulation/exercise:
Venous pressure (BP) ↑ to overcome constriction ➔ ↑ venous return
INSPIRATION ➔ ↑ RIGHT PRELOAD & ↓ LEFT PRELOAD
↑ murmur intensity on right & ↓ murmur intensity on left*
Breathing in ➔ diaphragm moves down ➔ expanded lungs & thoracic cavity
↓ intra-thoracic pressure ➔ ↓ RA pressure ➔ ↑ venous return
I think of it like a deep breath moves lungs away from my heart and vena cava
Makes it easier for blood to dump into RA via SVC
Diaphragm moving down ➔ ↑ intra-abdominal pressure (transient)
↑ ABD pressure with ↓ thoracic pressure shoots blood coming up IVC into RA
Blood pools in expanded lungs ➔ ↓ LEFT SIDED PRELOAD
VALSALVA/standing ➔ ↓ venous return ➔ ↓ preload
↓ murmur intensity on left *
Valsalva: if you tighten your ABD muscles you ↑ ABD pressure
When you bear down and hold that valsalva ➔ ↑ venous resistance ➔ ↓ venous return
Unlike the transient ↑ in venous return that happens when ABD pressure ↑'s during inspiration
Less blood in the heart means less blood to push out and make noise in left side*
SQUATTING (going supine, raising legs) ➔ ↑ RIGHT & ↑ LEFT PRELOAD
↑ intensity of all murmurs*
It is easier for blood to get to the heart when it doesn’t have to work against gravity
Squatting brings legs closer to heart but it also can ↑ afterload
Hand grip ➔ ↑ afterload
↑ intensity of murmurs of backwards flow on left
Resistance to getting blood out of the left means:
More regurgitation in AR and MR ➔ ↑ murmur
More L ➔ R in VSD ➔ ↑ murmur
* Outflow obstruction in hypertrophic obstructive cardiomyopathy is on the left but…
Less blood on left (↓ L preload) means more obstruction ➔ ↑ murmur intensity
* Mitral valve is on the left but…
Splitting of S2
PHYSIOLOGICAL SPLIT OF S2 (normal finding with inspiration)
Aortic valve (A2) closes then pulmonary valve (P2)
Blood pooling in pulmonary circulation ➔ shortened LV systole ➔ early aortic valve closure (A2)
↑ venous return right side ➔ prolonged RV systole ➔ late pulmonary valve closure (P2)
WIDE SPLIT
More pronounced during inspiration (A2 then P2)
↑ RV afterload ➔ prolonged RV systole or ↓ LV preload ➔ shortened LV systole
Pulmonary HTN, pulmonary stenosis, Severe MR, WPW, Constrictive pericarditis, RBBB
FIXED SPLIT
Doesn’t ∆ with inspiration (always there)
ASD: Communication between R and L negates pressure ∆ that occur with inspiration
PARADOXICAL SPLIT
Audible during expiration but not inspiration
HOCM, AS