1. Dynamic Auscultation Listening to the change in character, behaviour and the intensity of the heart sounds and murmurs to physiological and pharmacological maneuvers……. “AUSCULTATE WITH ALTERED HEMODYNAMICS”

2. Dynamic Auscultation • Source of murmur : Right Heart ~ Left Heart • Differentiate closely simulating murmurs Outflow ~ Regurgitatnt murmur • Differentiate flow murmurs from those of structural deformity : Austin Flint ~ MS • Differentiate Dynamic from Fixed Obstructions

3. Maneuvres PHYSI(OLOGI)CAL • Postural change Supine / L Lateral Standing Squatting • Valsalva • Handgrip • Cycle length change PHARMACOLOGICAL • Amyl nitrite • Phenylephrine

4. Position • Left lateral decubitus : Augments the murmur of MS, MR, Austin Flint, MVP & S1, LV S3 & S4 • Sitting & Leaning forward : ↑ AR murmur • Sitting with arms raised above the head : ↑ AR • Knee chest position : AR, Pericardial Rub • Passive leg raising : ↑ VR >↑ Right Heart events

9. Respiration • Inspiration augments right sided events, as the venous return increases : TR & TS , PR & PS murmurs ; RV S3,S4 & TV OS S1 & S2 split widen. • Exception is PES – augmented in expiration # Preferably quiet respiration # Avoid apnea # Listen the first few beats # In erect posture if Venous pressure is high

10. Carvallo’s sign • Inspiratory accentuation of TR murmur • Early systolic murmur > holosystolic • Blowing quality > musical • Absent in severe RV failure associated TS is severe • If venous pressure is very high, listening in upright posture may help

11. Reversed Carvallo sign HCM with RVO obstruction - ? ↑ VR > widened RVO

15. Respiration • Left sided events are better heard in expiration MR, MS, AS & AR murmurs LV S3 & S4, Mitral OS Click & murmur of MVP occur later @ PV – LA gradient increases > ↑ LV filling @ Lung overlap decreases @ Apnea for faint AR murmur

18. Pms = mean systemic pressure; Ppc = pulmonary capillary hydrostatic pressure; Ppi = pulmonary interstitial hydrostatic pressure; Ptm = pulmonary capillary transmural pressure

20. Abrupt standing • S2 split which may be wide, may narrow down , while the fixed split may persist • A2 OS interval widens – differentiates from wide split of S2 • All murmurs ( except MVP/HOCM) decrease • ESM of HOCM becomes louder and longer • Click occurs earlier, murmur becomes longer in MVP – loudness shows variable response

23. Isometric Hand Grip HAND DYNAMOMETER

25. Physiological changes of ISOMETRIC HANDGRIP EXERCISE

26. Isometric Hand Grip • LV S3 & S4 get augmented • Murmurs of MR,AR,VSD intensify • Mitral stenotic murmur may augment • Systolic murmur of HOCM may diminish • Click & late sytolic murmur of MVP get delayed

30. Transient Arterial Occlusion

32. Squatting • Increased venous return and CO > augments most murmurs atleast initially (AS,PS,MR,AR,VSD) Right heart murmurs do so earlier • Increased ventricular volume > murmur of HOCM ↓ murmur of MVP ↓→ • Ejection murmur of TOF ↑

34. P Hanson Br HeartJ7 1995;74:154

35. Central Aortic Pressure T Murakami AHJ 2002; 15:986–988

36. Hemodynamics of Squatting T Murakami AHJ 2002; 15:986–988

37. T Murakami AHJ 2002; 15:986–988

40. Valsalva Maneuver Decreased venous return & CO, HR ↑; PP↓ S2 split narrows down, S3 & S4 diminish

41. Valsalva Maneuver • Reduces the intensity of all murmurs except that of HOCM & MVP • Murmur of HOCM intensifies as the LV cavity size decreases • Click occurs earlier, the murmur lengthens in MVP – may not intensify • During release, the intensity of right heart murmurs returns earlier - 1 to 3 vs 5 beats for left heart murmurs

42. VALSALVA STRAIN

43. ASD, HF, MS

45. Cycle Length VariationPost premature beat / Long cycle short cycle of AF • Post VPD / Long > Short cycle of AF : Outflow murmurs ( AS/PS) accentuate Regurgitant murmurs do not change

47. Aortic Stenosis HOCM

48. Amylnitrite Inhalation • < 30 secs : Systemic vasodilatation • 30 – 60 secs : ↑ HR & CO • Augments S1, LV S3 & S4, TV & MV OS, murmurs of AS,PS,TR & HOCM • A2 – OS may widen • Diminishes the murmurs of MR, AR, VSD, PDA & Systemic AVF • Click & Murmur of MVP occur earlier

49. Amyl Nitrite Inhalation Augments Diminishes • Aortic stenosis Mitral regurgitation • Pulmonary stenosis TOF • Tricuspid regurgitation Mitral regurgitation • Mitral stenosis Austin Flint • Pulmonary regurgitation Aortic Regurgitaation

50. Phenylephrine • ↑ BP & SVR ↓ CO & HR – last for 3-5mts • Reduces intensity of S1, A2-OS may widen • Augments the murmurs of VSD, PDA, MR, AR, TOF, Systemic AVF • Diminishes AS, MS & functional murmurs • ESM of HOCM diminishes • Click & murmur of MVP get delayed