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Calcific aortic stenosis
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Left-sided valves
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- Systolic murmur: Rough, harsh ejection mesosystolic murmur (crescendo-decrescendo) at the 2nd right intercostal space (aortic area), classically radiating to the carotid arteries [G1-14] [V4].
- Gallavardin phenomenon: Acoustic dissociation in the elderly where the high-frequency component of the murmur is auscultated as musical and pure at the cardiac apex, mimicking mitral regurgitation [G1-14].
- Second heart sound (S2): Aortic component (A2) decreased, soft, or absent in severe forms due to extreme calcific cusp rigidity; possible paradoxical splitting of S2 [G1-11] [V4].
- Fourth heart sound (S4): Frequent in sinus rhythm due to atrial contraction against a non-compliant hypertrophied ventricle [G1-13].
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Aortic stenosis in bicuspid aortic valve
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Left-sided valves
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- Aortic ejection click: Sharp high-frequency early systolic click audible at apex and right/left sternal border, characteristic of mild and moderate forms where cusps retain elasticity and doming mobility; tends to diminish or disappear in severe forms as cusps become severely calcified and immobile [G1-02] [G1-16] [V4].
- Aortic systolic murmur: Diamond-shaped ejection mesosystolic murmur (crescendo-decrescendo) auscultated with maximum intensity at the 2nd right intercostal space (aortic area), radiating bilaterally to carotids [G1-14] [V4].
- Second heart sound (S2): Aortic component (A2) decreased in intensity and delayed, producing paradoxical splitting of S2 in severe stages [G1-11] [V4].
- Fourth heart sound (S4): Frequent due to vigorous atrial contraction against a stiff, hypertrophied LV [G1-13].
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Chronic aortic regurgitation
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Left-sided valves
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- Diastolic murmur: High-pitched, early diastolic decrescendo blowing murmur, auscultated with diaphragm at the 3rd left intercostal space / aortic area (site: aortic, pitch: high, shape: decrescendo) [V1] [V3] [G1-15].
- Associated systolic murmur: Mid-systolic ejection aortic murmur due to transaortic volume hyperflow (functional flow murmur) [V3] [G1-14].
- Austin Flint murmur: Apical low-frequency mid-diastolic rumble in severe forms due to displacement/vibration of the anterior mitral leaflet struck by the aortic regurgitant jet [V1] [V3] [G1-15].
- Heart sounds: Soft A2 [G1-11] [V1]; third heart sound (S3) in advanced stages with LV dysfunction [G1-12] [V1].
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Rheumatic mitral stenosis
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Left-sided valves
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- First heart sound (S1): Loud, snappy, and tapping (loud S1) in mild/moderate forms due to vigorous closure of pliable leaflets; softens in very advanced stages if the valve is heavily calcified [G1-01] [G1-10].
- Opening Snap (OS): High-pitched, sharp early diastolic sound following the second heart sound (A2). The A2-OS interval is inversely proportional to severity (the higher the left atrial pressure, the earlier the mitral valve opens: interval < 60–80 ms in severe stenosis vs > 100 ms in mild stenosis) [G1-01] [G1-15].
- Diastolic rumble: Low-pitched, rolling mid-diastolic murmur (rumble) auscultated with stethoscope bell at the apex in the left lateral decubitus position [G1-01] [G1-15].
- Presystolic accentuation: Late systolic / presystolic crescendo increase of rumble intensity due to active atrial contraction. Present only in sinus rhythm; completely absent once atrial fibrillation supervenes [G1-01] [G1-15].
- Second heart sound (S2): Accentuated pulmonary component (P2) in the presence of pulmonary hypertension [G1-11].
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Degenerative mitral regurgitation (flail P2)
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Left-sided valves
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- Holosystolic murmur: High-frequency regurgitant murmur beginning immediately with S1 and encompassing or extending beyond the second heart sound (S2) [V3] [G1-14].
Murmur radiation depending on flail leaflet:
- In chordal rupture of the posterior leaflet (most frequent): Regurgitant jet is directed eccentrically anteromedially toward the interatrial septum and aortic root, so the murmur radiates toward the cardiac base, aortic area, and carotids [V3] [G1-06] [G1-14].
- In anterior leaflet involvement: Jet is directed toward the posterior left atrial wall and radiates classically to the left axilla and back [V3] [G1-06] [G1-14].
- First heart sound (S1): Decreased or obscured by the early onset of the murmur [G1-10].
- Third heart sound (S3): Frequent at the apex due to increased rapid ventricular diastolic filling [G1-12] [V1].
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Acute mitral regurgitation from papillary muscle rupture
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Left-sided valves
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- Systolic murmur: Early decrescendo holosystolic or mid-systolic murmur (often soft, grade 2–3/6, or muffled due to early equilibration of LV-LA systolic pressures) auscultated at the apex [V1] [G1-14].
- Murmur radiation: In posteromedial papillary rupture (most common), the regurgitant jet is directed toward the anterior LA wall and aortic root, radiating toward the cardiac base and carotid arteries (mimicking aortic stenosis) [V3] [C9] [G1-06] [G1-14].
- First heart sound (S1): Decreased or muffled due to coaptation incompetence [G1-10].
- Added sounds: Persistent third heart sound (S3) [G1-12] [C9]; frequent fourth heart sound (S4) if sinus rhythm is present [G1-13] [C9].
- Second heart sound (S2): Loud P2 due to acute pulmonary arterial and venocapillary hypertension [G1-11] [C9].
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Mitral valve prolapse (Barlow disease)
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Left-sided valves
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- Non-ejection mid-systolic click: High-frequency, clicking, crisp sound produced by sudden tensing and checking of prolapsing redundant leaflets and elongated chordae during ventricular systole [G1-07].
- Late systolic murmur: High-frequency crescendo murmur starting after the click and extending up to the second heart sound (S2), auscultated at the apex [G1-07] [G1-14].
- First heart sound (S1): Usually normal or accentuated [G1-10].
- Second heart sound (S2): Normal or slightly accentuated [G1-11].
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Functional tricuspid regurgitation
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Right-sided valves
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- Holosystolic regurgitant murmur: Plateau systolic murmur auscultated at the 4th–5th left intercostal space at the lower left sternal border (LLSB), typically increasing in intensity with inspiration (Rivero-Carvallo sign) [B1] [G1-14].
- Right-sided third heart sound (S3): Right ventricular rapid filling third sound at LLSB that increases with inspiration in severe volume overload [G1-12].
- Second heart sound (S2): Accentuated pulmonary component (P2) if pulmonary hypertension coexists [G1-11] [C7].
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Rheumatic tricuspid stenosis
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Right-sided valves
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- Diastolic rumble: Low-pitched mid-diastolic rumble with presystolic accentuation (in sinus rhythm) auscultated at the 4th–5th left intercostal space at the lower left sternal border (LLSB), increasing in intensity with inspiration [G1-15] [B1].
- Tricuspid opening snap: High-frequency opening snap auscultated at the left sternal border, earlier than the mitral snap, moving earlier and becoming louder during inspiration [G1-15].
- First heart sound (S1): Accentuated and loud in the tricuspid area [G1-10].
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Valvular pulmonic stenosis (doming)
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Right-sided valves
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- Systolic ejection murmur: Harsh, raspy mid-systolic or mid-to-late systolic ejection murmur (diamond crescendo-decrescendo), auscultated with maximum intensity at the 2nd left intercostal space (pulmonic area), radiating to the left clavicle and interscapular region. Murmur duration prolongs and peaks later with increasing severity [G1-14] [G23-04].
- Pulmonic ejection click: High-frequency valve opening click audible in pulmonic area immediately after S1, characterized by its unique acoustic property of decreasing or disappearing during inspiration (inspiratory rise in RV end-diastolic pressure passively opens the leaflets prior to ventricular systole) [G1-16] [G23-04] [G23-05].
- Second heart sound (S2): Widely split S2 (S2 split wide), with markedly delayed and soft/muffled pulmonic component (P2) (P2 soft) due to prolonged right ventricular ejection time and stiff leaflets [G1-11] [G23-04].
- Right-sided fourth heart sound (S4): Frequent in severe forms due to forceful right atrial contraction against a stiff, hypertrophied right ventricle [G1-13].
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Pulmonic regurgitation
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Right-sided valves
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- Decrescendo diastolic murmur: Early to mid-diastolic murmur of soft quality and low/medium pitch, decrescendo, auscultated at the 2nd–3rd left intercostal space (pulmonic area and left sternal border), typically ending before S1 due to early cessation of the PA-RV diastolic gradient [G1-15] [V3]. (Semiologic note: In the absence of pulmonary hypertension, the murmur is not high-pitched or blowing like the Graham Steell murmur, but lower-pitched and briefer).
- Inspiratory increase: Loudness of the diastolic murmur increases with inspiration due to increased venous return and filling in the right-sided circuit [G1-15] [B1].
- Second heart sound (S2): Widely split S2, physiological or pathological secondary to conduction delay in the right bundle [G1-11].
- Right-sided third heart sound (S3): Present at LLSB in severe right ventricular volume overload [G1-12].
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Ostium secundum atrial septal defect
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Congenital heart disease
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- Second heart sound (S2): Wide and fixed splitting of S2 (S2 split fixed), unvarying with respiration, pathognomonic of atrial septal defect [G1-11] [G4-04].
- Systolic murmur: Soft ejection midsystolic murmur (grade 2–3/6) in pulmonary area due to hyperafflux across the normal pulmonary valve [G1-14] [G4-04].
- Tricuspid rumble: In severe form (G), soft mid-diastolic rumble in tricuspid area (lower left sternal border) due to relative tricuspid stenosis from high-volume flow [G1-15] [G4-04].
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Perimembranous ventricular septal defect
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Congenital heart disease
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- Systolic murmur in restrictive VSD (L/M): Harsh, high-frequency, loud holosystolic murmur (grade 4–6/6) with palpable thrill at 3rd-4th left intercostal space (lower left sternal border) [G1-14] [G4-05].
- Murmur in large VSD (G): Softer and shorter holosystolic murmur (grade 2–3/6) due to pressure equalization [G1-14] [G4-05].
- Second heart sound (S2): Accentuated pulmonic component P2 in severe forms with pulmonary hypertension (P2 loud) [G1-11] [G4-05].
- Mitral rumble: In severe forms with large shunt, functional mid-diastolic rumble at apex due to transmitral hyperflow [G1-15] [G4-05].
- Third heart sound (S3): Rapid filling gallop at apex in LV volume overload [G1-12].
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Patent ductus arteriosus
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Congenital heart disease
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- Continuous machinery murmur (Gibson murmur): Harsh, rough continuous murmur at 1st and 2nd left infraclavicular intercostal space (left subclavicular region), beginning in early systole, peaking in late systole enveloping the second heart sound (S2), and waning during diastole without interruption [G1-14] [G1-15] [G4-08].
- Thrill: Palpable continuous thrill in left infraclavicular fossa in moderate and severe forms [G4-08] [G4-09].
- Second heart sound (S2): Masked by continuous murmur peak; if audible, accentuated P2 if coexisting pulmonary hypertension [G1-11] [G4-08].
- Apical rumble: In large shunts (Qp:Qs > 2.0), functional mid-diastolic rumble at apex due to transmitral hyperflow [G1-15] [G4-08].
- Third heart sound (S3): Ventricular gallop at apex due to LV volume overload [G1-12].
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Aortic coarctation
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Congenital heart disease
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- Interscapular systolic / continuous murmur (back area): Midsystolic or late-systolic ejection murmur, audible in anterior left infraclavicular fossa but with maximal intensity in posterior left interscapular region (at level of T4–T6 over descending thoracic aorta) [G1-14] [G4-09].
- In severe forms with collaterals: Diffuse continuous or early systolic murmurs over dorsal and axillary chest wall due to flow through dilated intercostal arteries [G1-14] [G4-09].
- Second heart sound (S2): Accentuated aortic component (A2) due to high diastolic pressure in proximal aortic root [G1-11] [G4-09].
- Ejection click: Frequent at apex or aortic area if bicuspid aortic valve coexists (present in 50–70% of cases) [G1-16] [C5].
- Fourth heart sound (S4): Atrial gallop in severe forms with stiff left ventricular hypertrophy [G1-13].
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Post-infarction ventricular septal defect
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Complications of myocardial infarction
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- Harsh holosystolic murmur: Loud, harsh pansystolic murmur (grade 3–5/6) auscultated at lower left sternal border and radiating in cartwheel pattern toward right hemithorax and apex [C9] [G810-01] [B1].
- Tactile thrill: Palpable holosystolic thrill at left parasternal border [C9] [G810-01].
- Third heart sound (S3): Frequent S3 gallop due to volume overload [C9].
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