Musical Murmur Research Articles

Recognizing normal heart murmurs: a logic-based mnemonic.

A logic-based mnemonic for the auscultory diagnosis of nonpathologic murmurs, which I developed for teaching medical students and house staff, is presented with the hope of improving the auscultatory skills of primary care pediatric practitioners. The objective is positive identification of nonpathologic murmurs rather than diagnosis by exclusion. The auscultatory features of these murmurs are largely determined by their causative mechanisms. The logic, therefore, is based on an understanding of these mechanisms so that the listener will know why these murmurs have their characteristic sound features and specifically what to listen for. The logic can also be used in explaining nonpathologic murmurs to parents. The mnemonic device should reduce the need for rote memorization. Heart murmurs are present in most pediatric patients, and almost all are nonpathologic. Yet, the most common reason for referral to many pediatric cardiologists is for the evaluation of a heart murmur, two thirds of which are deemed normal.1,2 I believe that improving the accuracy of auscultation by primary care practitioners and improving their confidence in recognizing normal murmurs will decrease referrals to pediatric cardiologists, without underreferral of patients with heart disease. This outcome would be of significant psychologic and economic benefit to patients and their families. In referring to nonpathologic murmurs, the commonly used terms are innocent, functional, and normal. I prefer the latter. Perhaps, because “normal” is a less technical, more familiar word to parents, to me it seems easier for them to understand and accept the benign nature of these murmurs with this terminology. The formulation of the logic begins with a consideration of causative mechanisms. A heart murmur is a continuous series of sounds, with a variable number of different sound wave frequencies present at each instant. The wave frequency content of a murmur determines, to a large extent, …

Hemodynamic and anatomic factors affecting the frequency content of still's innocent murmur

S till’s innocent precordial murmur, also referred to as a vibratory or musical murmur, is found in many normal children and adolescents.’ The origin of this murmur has been attributed to vibrations of cardiac structures, turbulent blood flow, or minor pressure changes across normal valves.1-5 Still’s murmur has been associated with high aortic velocities4 and is accentuated by increased cardiac output. l4 This study evaluated the hemodynamic and anatomic factors associated with the frequency content of Still’s innocent murmur. Under a protocol approved by the institutional Human Subjects Committee, we evaluated 27 normal children (11 girls, 16 boys), aged 2.3 to 12.5 years (mean + SD 5.8 + 2.9) with no evidence of cardiac pathology and a Still’s murmur audible by auscultation. Aortic root diameter and left ventricular (LV) dimensions were measuredfrom parasternal M-mode recordings. Pulmonary artery diameter at the level of the valve annulus was measured from parasternal short-axis, 2-dimensional recordings. Ascending aortic velocities were measured by continuous-wave Doppler from the suprasternal notch and pulmonary velocities by pulsed Doppler from the parasternal short axis. Murmurs were detected, amplified, and analyzed using an MCG Spectra 3000 digital acoustic cardiography system (MCG International, New Haven, Connecticut). Murmurs were initially recorded on digital audio tape (model DTC-75ES, Sony Corporation, Tokyo, Japan) with the subject supine and resting quietly. Recorded murmurs later underwent 16-bit analog-to-digital conversion with real-time spec-

The “spasm score” on TCD Examination in the Patients with Vasospasms after Subarachnoid Hemorrhage.

TCD examination was performed in 71 patients with subarachnoid hemorrhage secondary to ruptured intracranial aneurysm. Delayed ischemic neurological deficits (DIND) accompanying vascular spasms were detected in 17 patients, but 10 of these recovered from the DIND within about 3 weeks. The TCD findings could be classified into four types according to their mean blood flow velocities (MBFV) . They consisted of: a) high pattern type, in which the MBFV had increased more than 100 cm/s (29 cases), b) low pattern type, in which the MBFV was less than 45cm/s (7cases), c) paradoxical pattern type, in which the MBFV was faster in the more peripheral regions (5 cases), and d) normal pattern type (30 cases) . From observation of the Doppler frequency, the sound of signals, and displayed waveforms, six characteristic findings were evaluated. (1) Filling-in of the systolic windows was observed in 16 out of 17 cases with DIND (23 out of 54 cases without DIND), (2) appearance of negative flow components was noted in all of the DIND cases (18 cases), (3) contour oscillation was viewed in 14 cases (10 cases), (4) high-intensity frequency was seen in 12 cases (14 cases), (5) musical murmur was heard in 8 cases (9 cases), and (6) disappearance of pulsatility was seen in 11 cases (10 cases) . From the observation of these six components, we made a“spasm score”on the TCD records. The score was 5.18±1.54 in the 17 patients with DIND, and 2.39±2.41 in 54 patients without DIND (p<0.001) . Sixteen patients out of 31 patients who had a spasm score of more than 3 suffured DIND, whereas, only one patient with a spasm score of less than 2 had DIND (p<0.01) . Hence this spasm score seemed to be very useful in the diagnosis of DIND in patients with vasospasms.

Echo-phonocardiographic study of musical murmurs

Echo-phonocardiographic study of musical murmurs

The incidental heart sound. Study of clinical diagnostic certainty and possible causes

The diagnosis "innocent murmur" is made when there is no evidence for a heart disease either by history nor by examination, auscultation, electrocardiogram or echocardiography. The purpose of the present study was to determine the usefulness of echocardiography for diagnosing of an innocent heart murmur and further to compare the findings of ultrasound with those of the clinical examination. Children were accepted for the study after clinical examination and evaluation of the electrocardiogram (but before echocardiography) only when two independent pediatricians did not realize any symptoms of a heart disease. A total number of 200 children were examined; 121 were male and 79 female. 194 children (97%) had an innocent murmur, six children (3%) a heart disease [atrial septum defect (3), bicuspid aortic valve (1), aortic stenosis (1) or pulmonary stenosis]. The sensitivity and positive predictive value of clinical examination and auscultation ranged from 92% to 99%, the specificity from 50% to 60%. In six cases the initial diagnosis had to be changed after echocardiography. Three times an innocent murmur was diagnosed as a heart disease and another three times a pathological murmur was regarded as innocent. Left ventricular bands were seen in 53 (26,5%) children and they significantly correlated with the musical heart murmur (77%). If there was no false tendon, the murmur was mostly an uncharacteristic one (74% (less than 0,001). The echocardiographic findings were not different of those children without a murmur or heart disease. The average peak velocity in the ascending aorta was 143,1 +/- 23,6 cm/s (87-215 cm/s), the shortening fraction 36,2 +/- 6,3%. We could not find a correlation between velocity, shortening fraction and aortic diameter.

Doppler study of precordial musical murmurs

Using phonocardiography, continuous- and pulsed-wave Doppler, 51 patients with precordial “musical” murmurs (49 with cardiac abnormalities) and 21 patients with noisy murmurs were examined. With M-mode echocardiography, fine fluttering of the structure generating the murmur was evident in 23 patients with musical murmurs and in 5 with noisy murmurs. A continuous-wave Doppler spectral signal characterized by parallel harmonics (Doppler musical signal) was evident in all patients with musical murmurs and in none with a noisy murmur. With pulsed-wave Doppler, the musical signal had less defined spectral features because of range ambiguity. Such a signal was experimentally reproduced by activating a diapason bathed in saline solution. The source of the musical murmur was established in all 51 patients by Doppler. The musical signal was associated with a valvular regurgitation signal was associated with a valvular regurgitation signal in 36 patients and with a ventricular septal defect in 1 patient. The musical signal always disappeared when the pulsed-wave Doppler sample volume was placed 2 cm away from the generating structure. In 11 patients with musical murmur examined by color Doppler, no abnormal bidirectional flow signal was observed in the structures generating the signal. In 6 of the patients without valvular regurgitation, no flow disturbance was found. In conclusion, Doppler is valuable in determining the source of musical murmurs, and musical murmurs are caused by a vibrating structure even in the absence of flow turbulence.

Genesis of vibratory functional murmurs

The genesis of the vibratory systolic murmur heard in so many normal children has never definitely been established. In 1 case report, Roberts 1 attributed a loud musical murmur to a 2 mm-diameter band stretching across the left ventricular outflow tract. In a more recent study Perry et al 2 found left ventricular false tendons in 31 of 3,847 (0.8%) consecutive cross-sectional echocardiograms. A precordial murmur, most commonly vibratory, was heard in 14 of the 16 without associated heart disease. There seemed, then, to be an association of such murmurs with false tendons. Brenner et al 3 reported a 61% prevalence of left ventricular false tendons, but noted no correlation with any variety of murmur.

Late diastolic whoop in severe aortic regurgitation

Musical murmurs appear in systole as part of ejection or regurgitant murmurs and are often called “honks” or “whoops.” 1–3 Musical murmurs in diastole also have been described in aortic regurgitation (AR), in early to mid-diastole or throughout diastole. 4–6 This report describes a patient with a late diastolic whoop related to AR.

Association of false tendons with left ventricular aneurysm

False tendons are well recognized structures of the left ventricle. They are fibromuscular strings joining 2 ventricular walls or 2 papillary muscles, distinct from the chordae tendineae, which join papillary muscles to mitral valve leaflets. These structures can be identified using 2-dimensional echocardiography. 1 The reported frequency of false tendons in children has varied 2,3; that in adults is about 5%. 4 False tendons have been suggested as a cause of precordial musical murmur. 5 To our knowledge, no causative association with any heart disease has been shown. 4,6 We describe a patient with echocardiographic evidence of a chordal structure corresponding to a false tendon associated with a left ventricular (LV) aneurysm. We have encountered 4 other patients with similar abnormalities.

Musical murmurs: Clinical implications, long-term prognosis, and echo-phonocardiographic features

Musical murmurs: Clinical implications, long-term prognosis, and echo-phonocardiographic features

Musical murmurs in human cerebral arteries after subarachnoid hemorrhage.

A transcranial ultrasonic method for the recording of murmurs from cerebral vessels is described. Using the new approach the authors have observed musical murmurs of pure tone quality in 15 patients with increased flow velocities in the cerebral arteries after spontaneous subarachnoid hemorrhage (SAH). The frequency range of the pure tones was from 140 to 820 Hz, corresponding to flow velocities between 73 and 215 cm/sec. The musical murmurs occurred as a transitional state between silent flow and the well known phenomenon of bruit. They were observed between the 4th and the 20th day after SAH. The most likely cause of the musical murmur is a periodic shedding of vortices in the cerebral arteries, commonly referred to as "a von Kármán vortex street." Clinically the presence of musical murmurs indicated that pathologically increased blood velocities were present in the artery under investigation. This probably reflected the degree of spasm.

Origin and clinical relevance of musical murmurs

Although our observations are limited to studies performed on a degenerated bioprosthetic valve that produced a musical murmur, we believe that they can be applied to musical murmurs caused by abnormal natural valves. Several points regarding the characteristics of musical murmurs have been clarified. 1. (1) A musical murmur results from a uniform periodic vibration of a cardiac structure. 2. (2) A non-musical murmur results from turbulent blood flow which initiates random vibrations of adjacent structures. The broad spectrum of frequency of a non-musical murmur reflects the broad range of random fluctuations of blood velocity that characterizes turbulent blood flow. 3. (3) The frequency, amplitude, and time of occurrence during systole or diastole of a musical murmur are dependent upon the hemodynamics in the vicinity of the vibrating structure. Variability of all of these characteristics of the murmur, therefore, may be expected. 4. (4) Musical murmurs may have a purer tone at a site distal to the source than close to the source. This may reflect a superimposition of a broad spectrum of noise due to turbulence close to the valve. With distance from the valve, turbulence attenuates more than the sound-pressure fluctuations which are due to the uniform vibrations of the valve. A pure tone, uncontaminated by this broad spectrum of noise due to turbulence, therefore, is heard at some distance from the valve.

Echo-phonocardiographic features of regurgitant porcine mitral and tricuspid valves presenting with musical murmurs

Echophonographic findings of three patients with spontaneous degeneration of porcine tricuspid and mitral valves presenting with musical murmurs are reported. Echocardiography in all these patients revealed systolic or diastolic cusp flutter similar in frequency to the musical murmur on simultaneously recorded phonocardiogram. Porcine tricuspid regurgitation is usually well tolerated and can be followed clinically for many years. However, patients with mitral porcine valves usually become symptomatic or present with congestive heart failure and usually require valve surgery soon after clinical or echo-phonocardiographic findings of valve regurgitation appear.

A case of sereve Annuloaortic ectasia with low frequency musical murmur:

A case of sereve Annuloaortic ectasia with low frequency musical murmur:

Hemodynamic determinants of the frequency and amplitude of a musical murmur produced by a regurgitant mitral bioprosthetic valve

The purpose of this study was to assess the hemodynamic determinant of the amplitude and frequency of a musical murmur produced by a regurgitant degenerated bioprosthetic valve in the mitral position. The prosthetic valve, obtained at surgery, was studied in the mitral position of an in vitro pulse duplicating system. In vitro, the valve produced a musical murmur that was caused by flutter of a flail leaflet. When the peak pressure difference between the left ventricle and left atrium was increased from 95 to 150 mm Hg, the fundamental frequency of the musical murmur increased from 91 to 187 hertz and the amplitude increased from 2,080 to 11,420 dynes/cm 2. The fundamental frequency of the musical murmur was linearly related to the peak systolic pressure difference between the left ventricle and the left atrium (correlation coefficient [r] = 0.99). Similarly, the fundamental frequency of the musical murmur was linearly related to the magnitude of regurgitant flow across the valve (r = 0.99); and the regurgitant flow as expected was linearly related to the systolic pressure difference between the left ventricle and left atrium. The amplitude of the musical murmur was also related to both the peak systolic pressure difference between the left ventricle and left atrium (r = 0.99) and the magnitude of regurgitant flow (r = 0.99). These results indicate that the magnitude of regurgitant flow, determined by the systolic pressure difference between the left ventricle and left atrium, was a determinant of both the amplitude and the frequency of the musical murmur.

Mechanism of a musical systolic murmur caused by a degenerated porcine bioprosthetic valve

The cause of a musical (cooing) murmur produced by a degenerated bioprosthetic valve in the mitral position was investigated. Spectral analysis of the murmur recorded at the chest wall at the site of the maximum palpable impulse showed virtually all sound in a narrow frequency band around the dominant frequency of 158 hertz. The same valve, surgically removed and mounted in the mitral position in a pulse duplicating system, produced an audible musical murmur detected by a phonocatheter in the atrial chamber. Nearly all of the sound-pressure occurred in a narrow band of frequency around 145 hertz. High speed motion pictures (500 frames/s) showed systolic flutter of a flail leaflet. The frequency of this leaflet flutter was 142 hertz. Hot film anemometry showed minimal turbulence, all located near the margin of the regurgitant leaflet. The intensity of the murmur was unrelated to the intensity of turbulence. A second degenerated bioprosthetic valve that produced in vivo a typical blowing holosystolic mitral regurgitant murmur produced in vitro a murmur with a broad range of frequencies (20 to 500 hertz). With this valve, the intensity of the murmur was related to the intensity of the turbulence. Motion pictures showed no leaflet flutter. Flutter of an insufficient valve leaflet causing uniform and periodic high frequency fluctuating pressures therefore appeared to be the cause of the musical quality of the systolic murmur in a degenerated bioprosthetic valve.

Newly developed systolic murmur in patients with a transvenous pacemaker

We encountered four cases in which a transvenous cardiac pacemaker produced a systolic musical murmur in the absence of any complications. This systolic murmur appeared only when the pacing was being cut off and disappeared soon after the pacing had been turned on. Although the exact mechanism of production of the murmur remains uncertain, several possible mechanisms for its occurrence are discussed. It is apparent from this study that a systolic murmur can newly occur without any obvious cause in patients with a transvenous pacemaker.

Diastolic Flutter of Aortic Valves in Aortic Regurgitation: A Report of Seven Cases

Seven patients with aortic regurgitation, manifesting diastolic flutter of the aortic valve cusps (DFAVC) in the echograms, are described. Five patients with infective endocarditis revealed coarse or fine, irregular DFAVC. Two patients with severe aortic regurgitation and a musical murmur manifested regular DFAVC with a frequency identical to that of a simultaneously recorded diastolic murmur. Of the 5 patients with infective endocarditis, 4 required urgent aortic valve replacement and 1 died. The 2 patients with musical murmurs are clinically stable without surgery. This report extends the clinical spectrum of patients with DFAVC and describes the character of the flutter in patients with muscial murmurs. Furthermore, it suggests that DFAVC is a sign of severe aortic regurgitation.

Musical murmurs: An echo-phonocardiographic study

Five patients with musical murmurs were studied noninvasively with simultaneous echocardiography and phonocardiography. Three patients had aortic regurgitation, one mitral regurgitation and one tricuspid regurgitation. The frequency of the musical murmurs ranged from 40 to 158 cycles/sec. The patient with tricuspid regurgitation manifested an inspiratory honk. Simultaneous echo-phonocardiography revealed regular valve leaflet flutter (aortic, mitral or tricuspid) at a frequency identical to that of the simultaneously recorded musical murmur. This study demonstrates that echocardiography is a useful noninvasive tool in identifying the site of origin of musical murmurs.

Gallavardin Phenomenon in Aortic Stenosis

In 1925, Gallavardin reported that the harsh murmur of aortic valvular stenosis could change in quality and become musical at the apex.1He postulated that the high-pitched musical components of the murmur of aortic stenosis were preferentially transmitted to the apex through solid tissues, whereas the lower-pitched components were transmitted to the neck vessels via the flow of blood. Subsequently, Gallavardin's findings have been noted by others.2-5Thus, the Gallavardin phenomenon and its proposed mechanism have become well accepted. While recently studying a patient with aortic stenosis and the Gallavardin phenomenon, it occurred to us that the high-pitched musical murmur might be secondary to the development of papillary muscle dysfunction. The following evidence is presented to support this hypothesis. Patient Summary A 30-year-old man was admitted to the Tulane Cardiology Service at the Charity Hospital of Louisiana at New Orleans for evaluation and treatment of severe aortic stenosis