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.