Diastolic noises

The first heart murmurs were described more than 200 years ago (Rishaniw 2018).

The Parisian physician Rene Theophile Hyacinthe Laennec (1781 - 1826) used the ear trumpet he developed during his rounds in a clinic for lung patients and thus developed a vocabulary for normal, abnormal and pathological murmurs (Schoon 2012).

The Graham- Steell sound is named after its first describer (Graham Steell 1851 - 1942) (Kasper 2015).

In 1907, Carey Franklin Coombs (1879 - 1932) first described the Carey- Coombs noise named after him (Robbins 2022).

Austin Flint (1812 - 1886), a New York internist, suspected the mechanism of origin to be aortic valve insufficiency already in the mid-19th century and therefore the Austin Flint murmur was named after him (Gahl 2014).

A diastolic murmur is a high-pitched opening murmur (OS) of the heart during the filling phase (diastole) that can be perceived by auscultation and occurs in certain diseases (Kasper 2015). A diastolic murmur is always pathological (Herold 2022).

Diastolic murmurs are differentiated between:

• Diastolic regurgitation murmurs: These regurgitation murmurs are caused by an insufficiency of the semilunar valves (Haas 2017).
• Diastolic filling murmurs: This occurs due to an increased blood volume flowing across the AV valve. Increased blood volume can occur, for example, due to a shunt vitium. This is therefore referred to as "relative AV valve stenosis". True AV valve stenosis is very rare (Haas 2017).

Continuous systolic-diastolic murmurs (so-called machine murmurs):

These murmur phenomena result from a shunt connection between the high and low pressure systems (Herold 2022).

Cardiac murmurs are characterized by

• volume:
  • 1 / 6: Very quiet sound, which can be auscultated only with difficulty.
  • 2 / 6: Quiet, but clearly audible
  • 3 / 6: Loud heart murmur without buzzing
  • 4 / 6: Loud murmur with murmur
  • 5 / 6: Very loud heart murmur, audible immediately after placing the stethoscope on the patient's head
  • 6 / 6: Loud murmur which can be heard without stethoscope
• Frequency
• Punctum maximum
• Conduction
• Position in relation to heart sounds
• Palpation of the carotid pulse
• Type of sound:
  • Decrescendo-
  • Spindle-
  • Band-
  • crescendo form (Herold 2022)
• Duration:
  • early diastolic
  • late-diastolic
  • mid-diastolic (Haas 2017)

The diastolic murmur occurs during diastole (Haas 2017), in a very short interval after the 2nd heart sound (Kasper 2015). One differentiates diastolic murmurs between:

• diastolic regurgitation murmurs: These regurgitation murmurs are caused by an insufficiency of the semilunar valves (Haas 2017).
• diastolic filling murmur: This occurs due to an increased blood volume flowing across an AV valve (Haas 2017). The murmur is low frequency (Gahl 2005). An increased blood volume can occur, for example, due to a shunt vitium. Therefore, one speaks of a "relative AV-valve stenosis". A true AV-valve stenosis occurs only very rarely (Haas 2017).

A diastolic murmur is always pathological (Herold 2022).

Diastolic murmurs may occur with:

• Stenosis of the AV valves
  • 1st caused by mitral valve stenosis and referred to as a "mitral opening tone". This sound is high frequency, early diastolic, and occurs at the end of the opening motion of the mitral valve. Punctum maximum are cardiac apex and Erb's point. The diastolic may be absent in mild forms of mitral valve stenosis and may disappear over time in severe forms. It is also absent in absolute arrhythmia (Füeßl 2010).
• Functional AV-valve murmur due to increased blood flow in e.g.:
  • AV-valve insufficiency see mitral valve insufficiency and tricuspid valve insufficiency
• Insufficiency of the semilunar valves
  • due to organically caused valve defects such as aortic valve insufficiency (audible as a short, high-frequency diastolic sound [Füeßl 2010])
  • due to overdistension of the valve annulus together with pulmonary hypertension in e.g. relative pulmonary valve insufficiency (Herold 2022). Auscultatorically, there is a high-frequency descrescendo murmur with p. m. in the 2nd or 3rd ICR, also known as a so-called Graham- Steell murmur (Kasper 2015).
• Functional murmur of the AV valves due to increased blood flow, e.g., in AV valve insufficiency (Herold 2022), see also mitral valve insufficiency and tricuspid valve insufficiency.
• Tricuspid valve stenosis (however, this occurs only rarely)
• severe mitral regurgitation as Carey-Combs murmur
• severe aortic regurgitation as Austin- Flint- murmur
• atrial myxoma
• Atrial septal defect: In addition to the systolic, there may be a low-frequency diastolic with p. m. above the inferior sternal border or a high-frequency diastolic with p. m. above the base (Gahl 2005).
• Ventricular septal defect: Again, in addition to the systolic [Siegenthaler 2005]), a diastolic may exist with a large shunt due to relative mitral stenosis (Gahl 2005).
• Z. n. mitral valve replacement (Sato 2016).

• Continuous systolic-diastolic murmurs (so-called machine murmurs).

This murmur phenomenon occurs in the following diseases:

- aorto-pulmonary window

- ruptured sinus Valsalva aneurysm

- open ductus botalli

- coronary fistulas

- arteriovenous fistulas due to e.g. pulmonary angioma or posttraumatic (Herold 2022)

Heart murmurs are caused by the formation of a vortex. If this goes posteriorly, stenosis occurs; if it goes anteriorly, insufficiency occurs (Herold 2022).

The diastolic murmur is inversely proportional to the magnitude of the diastolic pressure gradient between the left atrium and left ventricle (Kasper 2015).

A diastolic murmur is always an indication for echocardiography.

The diagnosis of diastolic murmurs otherwise includes auscultation, pulse oximetry, ECG, MRI, CT (Haas 2017).

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