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Rao. Vessel Plus 2022;6:22 https://dx.doi.org/10.20517/2574-1209.2021.105 Page 11 of 24

cardiac abnormalities in three out of 62 (4.8%) patients. In addition, this study indicated that the referring
physician’s expectation is that an echocardiogram is performed as part of cardiac evaluation. While the
author continues to believe that echocardiogram is not necessary for patients with a clear-cut diagnosis of
functional or innocent murmurs, an echo may be performed if requested by the parents or referring
physician.

Other etiologies of ejection systolic murmurs [Table 2]
“Ejection” type of murmurs may also be heard in patients with mitral valve prolapse. This diamond-shaped,
crescendo-decrescendo murmur is auscultated at the apex, usually late in systole. A mid-systolic click
precedes the murmur. Echocardiogram is helpful in documenting mitral prolapse.

Patients with a diagnosis of acyanotic tetralogy of Fallot may have an ejection systolic murmur due to flow
across the stenosed infundibulum. This murmur is usually heard at LMSB and LUSB, peaks early in systole
when compared with PS with the intact ventricular septum. Pink tetralogy should be considered when the
examiner hears a murmur all along the left sternal border. The RV impulse is increased, and the 2nd heart
sound is single. ECG demonstrates RVH. Echo-Doppler studies demonstrate a large VSD, a large ascending
aorta that overrides the inter-ventricular septum, RVH, and Doppler evidence of RV outflow tract
obstruction.

Some subjects with PDA may exhibit ejection systolic murmur. These examples are either neonates or older
patients with elevated PA pressures and resistance. The diastolic part of the PDA murmur is not present
because of increased pulmonary vascular resistance. Multiple ejection clicks buried within the murmur, and
bounding pulses are useful in the diagnosis of PDA. Echo-Doppler studies confirm the diagnosis.

Holosystolic murmurs
The etiology of holosystolic murmurs is shown in [Table 3]. Location where the murmur is heard best,
where it radiates to, and change in intensity of the murmur with respiratory cycle are useful in the
differential diagnosis of these defects [Table 5]. Of course, the findings of the ECG and chest roentgenogram
are useful in making a diagnosis. Echo-Doppler studies are confirmatory.

Ventricular septal defect
Holosystolic murmurs of VSD are auscultated best at the lower left sternal border; these murmurs do not
radiate. However, the murmur may be auscultated widely across the entire precordial area in some patients.
This murmur does not exhibit respiratory variation. This murmur is produced by blood flow across the
VSD during systole. In subjects with extremely small ventricular defects, the murmur may be auscultated
[2]
best at the mid left and rarely at upper left sternal borders. The murmur usually varies between grades II
and V/VI in intensity. The loudness of murmur has no relationship with the diameter of the VSD. In
patients who have small VSDs, the murmur begins with the 1st heart sound, but does not last through the
whole systole. The briefer the murmur, the smaller the VSD. Small muscular VSD may have a “squirty” or
“bicycle pump” quality of murmur. Increased LV impulse may be present in moderate and large VSDs.
Increase in both right and left ventricular impulses may be felt in patients with large VSD. Only increase in
RV impulses is seen in patients with high PA pressures and those who have developed pulmonary vascular
obstructive disease (PVOD). A thrill may be appreciated at the lower left and/or mid left sternal borders.
Splitting of the 2nd sound is heard, although it may be single if there is PVOD. The second (pulmonary)
component of 2nd heart sound may be normal in small and moderate-sized VSDs, but is loud in subjects
with large defects with elevated pulmonary artery pressure. Clicks are uncommon in VSD patients;
however, they have been described in subjects with spontaneous closure of VSDs by aneurysmal formation