SPECIAL MANEUVERS

Auscultation aids to facilitate diagnosing murmur

Squatting

  • Standing from a squatting position

    Rapid standing from squatting position (held for 30+ seconds) increases murmur intensity for first 15-20 seconds

  • Squatting from sitting or standing position
    • Causes increased intensity of murmurs except MVP to increase
    • MVP decreases; both click and murmur will move later into systole
    • Helps distinguish MR from MVP
      • MR intensity increases
      • MVP intensity decreases

  • Patient must avoid Valsalva maneuver which will confound results
  • Place diaphragm on LLSB ; patient moves rapidly from standing to squatting
  • Repeating several times

Passive straight leg raising and sudden recumbency

  • Useful where patient cannot perform squat-sit maneuvers
  • Can also bend patient's legs toward abdomen
  • Augments venous return thus emphasizes right and left filling
  • Causes most murmurs to increase
  • MVP decreases

Valsalva maneuver

  • Forced expiration against a closed glottis
    • Adults: instruct to strain as though moving bowels; examiner hand on abdomen
    • Child: instruct to place thumb in mouth and blow hard against it
  • Useful to distinguish left-sided vs right-sided murmurs
  • Left-sided murmurs take longer to recover maximum intensity
    • Breath release causes sudden increased right side filling
    • Increased filling accentuates right-sided event
    • Initial effect is to decrease venous return to hear

Isometric Handgrip Maneuver

    • Clench fist forcefully or squeeze rolled up washcloth
    • Position palms together with fingers toward wrist of opposite hand as patient pulls two hands in opposite direction

  • Accentuates ventricular and atrial gallop sounds
  • Accentuates left-sided regurgitant murmurs
  • Reduces left-sided outflow tract murmurs
  • Faint diastolic rumble of MS may be accentuated
  • Accentuates MR but also accentuates VSD thus cant distinguish between them
  • Accentuates S3 and S4 in 50% of patients with CHD or CHF
  • May decrease AS

Carvallo's Maneuver

  • Carvallo's sign: aids in diagnosis of tricuspid regurgitation
    • Murmur increases during deep inspiration followed by post-inspiratory apnea
    • Must avoid Valsalva maneuver

  • OTHER EFFECTS OF MANEUVER
    • Accentuates splitting of S2
    • Accentuates right-sided S3 (does not accentuate left-sided S3)
    • Ejection click of pulmonary stenosis decreases or disappears during inspiration
    • Accentuates diastolic murmur of tricuspid stenosis (distinguishes from mitral stenosis)
    • Assists in the differential diagnosis of holosystolic murmur
      • Only tricuspid regurgitation increases during inspiration
      • Other holosystolic murmurs do not increase: VSD, AS, PS
    • Presence of right-sided failure of extracardiac factors may interfere
SPECIAL MANEUVERS AND POSITIONING
Aortic Stenosis Best heard with patient sitting and leaning forward in expiration. Decreases with hand grip
Mitral regurgitation Best heard in left lateral decubitus. Increases with hand grip
Aortic regurgitation Best heard sitting, learning forward with expiration. Increases with hand grip. The more severe the murmur, the longer it's duration. Associated murmurs occur due to ventricular overload (systolic flow murmur) or because backflow displaces anterior leaflet of mitral valve creating a soft, low-pitched diastolic murmur at apex (Austin-Flint)
Mitral stenosis Best heard with bell placed softly on apical impulse; patient exhaling in left lateral position. Often associated with pan-systolic murmur of tricuspid regurgitation with comorbid pulmonary hypertension. With atrial fibrillation, presystolic accentuation disappears
Mitral valve prolapse Increased intensity on rising from squatting position to standing position and with Valsalva. Squatting causes MVP murmur to decreases; both click and murmur will move later into systole. Maneuvers which decrease size of ventricle move click and murmur earlier into systole.
Innocent murmur Usually decreased with sitting; should occur early in systole;crescendo-decrescendo. Should NOT be associated with any clicks, extra sounds, abnormal splitting, diastolic murmurs or any other suspicious findings such as abnormalities in pulse, apical impulse, blood pressure.
Tricuspid stenosis Carvallo's sign accentuates murmur
Tricuspid insufficiency Carvallo's sign: tricuspid regurgitation murmur increases with deep inspiration followed by post-inspiration apnea.