Murmurs and Valve Lesions


  • Description of a murmur


(1) Timing

  • systole/diastole/continuous
  • early/mid/late/pan

(2) Area of greatest intensity

(3) Loudness

  • grade 1 (very soft/consultants)
  • grade 4 (thrill)
  • grade 6 (no stethoscope required)

(4) Pitch

  • low (low pressure)
  • high (high pressure)

(5) Changes with Dynamic Manoeuvres

  • respiration (RILE)
  • squatting (makes most murmurs louder, except HOCM and MVP)
  • isometric exercise (AS, HOCM and MVP softer, other murmurs louder)
  • Valsalva:
    • -> straining -> HOCM and MVP softer
    • -> release -> first R sided murmurs increase then left sided


  • MR
  • TR
  • VSD
  • Aorto-pulmonary shunts


  • AS
  • PS
  • HOCM
  • Pulmonary flow murmur of an ASD


  • MVP
  • Papillary muscle dysfunction (due to ischaemia or HOCM)


  • AR
  • PR


  • MS
  • TS
  • Atrial myoxoma
  • AR (Austin Flint murmur – low pitched rumbling mid-diastolic and presystolic murmur @ apex -> shuddering of anterior leaflet of mitral valve)
  • Carey Coombs murmur of acute rheumatic fever


  • MS
  • TS
  • Atrial myxoma


  • PDA
  • Arteriovenous fistula (coronary artery, pulmonary, systemic)
  • Aorto-pulmonary connection (e.g. congenital, Blalock shunt)
  • Venous hum
  • Rupture of sinus of Valsavla into right ventricle or atrium
  • ‘Mammary souffle’ – late in pregnancy or early post partum period


SymptomsPND, orthopnea, palpitations, Chest Pain Pedal oedema, Chest Pain, SOBChest Pain, Short Of Breath
Pulse Commonly AF May be AF Usually Sinus Rhythm
JVPMay be raisedV wavesProminent a waves because of pulmonary hypertension
PrecordiumSystolic Thrill +/- Parasternal lift +/-Systolic Thrill +/- Parasternal lift +/-Systolic Thrill +/- Parasternal lift +/-
MurmurApical to axillaLeft Sternal Border, increases with inspirationLeft Sternal Border, occasionally concomitant Atrial regurg
Other systemic signsBasal crepitationsPulsatile liverOther congenital abnormalities +/-
Chest X-RayStraight Left heart border, pulmonary oedemaEnlarged Right AtriumNil specific
EchoClassic featuresClassic featuresClassic features
Pulmonary Artery CatheterPulmonary hypertensionPulmonary hypertension, V waves on Central Venous PressureStep up in O2 saturation at ventricular level

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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