Murmur Deep

Dive !
MPAN 624 Health History and Physical Diagnosis I
Spring 2024
Thank you to Erin Frawley, MMS, PA-C for creating
this lecture.
Lecture Objectives
• Review relevant anatomy and physiology pertaining to the cardiovascular system.
• Review how to accurately perform a physical examination of the cardiovascular system.
• Describe normal and abnormal physical exam findings of the cardiovascular system.
• Recognize signs and symptoms of medical and surgical conditions associated with the
cardiovascular system.

2
Auscultation –
Murmurs
Murmurs – sounds reflecting turbulent
blood flow through a valve
• Amount of turbulence and intensity
depends on:
• Size of the valve
• Size of the chamber
• Pressure gradient
• Volume of blood flow
Auscultation –
Murmurs
• Describe the following about a
murmur:
• Location – where heard the loudest
• Radiation!
• Timing – systolic vs diastolic,
duration (early, mid, late)
• Shape – crescendo, decrescendo,
crescendo-decrescendo
• Intensity – graded 1-6 (systolic) or
1-4 (diastolic)
• Pitch – high, medium, low
• Quality – blowing, harsh, rumbling,
musical
• Accentuation or diminished with
certain positions
 Murmur Descriptors –
Location and Radiation
• Location of auscultation identifies the valve involved
• R 2nd ICS – Aortic valve
• L 2nd ICS – Pulmonic valve
• L 3rd ICS (Erb’s point) – Pulmonic valve
• L 4th ICS - Tricuspid
• L 5th ICS - Tricuspid
• Apex - Mitral valve
• Loudest near the point of origin
• Sounds can radiate and area of radiation is important to note
• See image for areas of radiation
• In addition (not pictured but need to know)
• Aortic valve radiates to suprasternal area, neck / carotids
• Mitral valve radiates to axilla, L scapula
Murmur Descriptors – Timing During Cardiac Cycle
Systolic Murmurs:
• Heard between S1 and S2
• Mid-systolic murmurs are most
common
• Can be innocent (no detectable
physiologic or structural abnormality),
physiologic (due to changes in
metabolism) or pathologic (due to
cardiac structural abnormalities)
Diastolic Murmurs:
• Heard between S2 and S1
• Always pathologic
• Early diastolic are typically regurgitation
murmurs
• Late diastolic are typically stenosis of an
AV valve (usually mitral)

6
Murmur Descriptors – Timing
Murmur Descriptors – Timing
Murmur Descriptors - Shapes
• The shape is the change in
intensity through the cardiac
cycle
• Crescendo
• Builds / grows louder
• Decrescendo
• Grows softer
• Crescendo – decrescendo
• Rises then falls (diamond shape)
• Plateau
• Same throughout
Murmur Descriptors – Intensity / Grade
Murmur Descriptors -
Pitch
• High
• Medium
• Low
Murmur
Descriptors –
Quality
• Blowing
• Harsh
• Rumbling
• Musical
Special
Maneuvers
Utilized to better identify
and further characterize
(accentuate or diminish)
murmurs
Special Maneuvers
Once a murmur is identified and described by the criteria above, you
must also utilize these special maneuvers to either accentuate or
diminish the murmur, further supporting the identification and
diagnosis.
• 6 positions / maneuvers:
o Left lateral decubitus
o Leaning forward, exhale completely and hold breath
o Standing and squatting position
o Valsalva
o Isometric handgrip
o Transient Arterial Occlusion
Special Maneuvers – Left lateral decubitus
• Start with the patient in the supine position
• Place your stethoscope where you hear the
murmur the best / loudest location
• The move your patient into the left lateral
decubitus position, noting the intensity of
the murmur

Left lateral decubitus position accentuates

the murmur of mitral stenosis

15
Special Maneuvers – Lean
forward, exhale and hold
breath

• Start with the patient in the supine position

with HOB at 30 degrees
• Place your stethoscope where you hear the
murmur the best / loudest location
• Instruct your patient to sit up, lean forward,
exhale completely and hold their breath,
noting the intensity of the murmur
• Accentuates aortic regurgitation

16
Special Maneuvers – Standing /
Squatting
• Position yourself next to your patient in the
standing position
• Place your stethoscope where you hear the
murmur the best / loudest location
• Ensure your patient is stable / brace your
patient
• Note the intensity of the murmur and how it
changes as you squat down and then stand
with the patient
• Accentuates the murmur of hypertrophic
obstructive cardiomyopathy and mitral
valve stenosis during squatting to standing
• Decreases the same murmurs (HCM and
MVP) with standing to squatting

17
Special Maneuvers – Standing / Squatting

The murmur
of aortic
stenosis has
the opposite
pattern of
HCM and
MVP during
Standing /
Squatting
Special Maneuvers - Valsalva maneuver
• With your patient in the supine
position with the HOB at 30
degrees
• Place your stethoscope where you
hear the murmur the best / loudest
location
• Ask your patient to “bear down like
you are having a bowel
movement”
• Alternative: place your hand on the
patient’s lower abdomen and ask
your patient to push against it
Note the intensity of the murmur during the 4 phases
of Valsalva
• Phase one / Strain phase: onset of straining causes
increased intrathoracic pressure.
• Quick rise in BP
• Hypertrophic cardiomyopathy murmur is the ONLY
murmur that will be increased during the strain
phase of Valsalva (due to the outflow obstruction)
• Phase two / Strain maintained: decreased venous
return, resulting in decreased stroke volume & pulse
pressure.
• HR increases and BP drops
• Phase three / Release phase: release of straining with
decreased intrathoracic pressure
• HR and BP continue to drop
• Phase four / Overshoot: Blood pressure rises due to
reflex sympathetic activation and increased stroke
volume
19
Special Maneuvers – Isometric Handgrip
• Start with the patient in the supine
position with HOB at 30 degrees
• Place your stethoscope where you
hear the murmur the best /
loudest location
• Instruct your patient to squeeze
both hands, noting the intensity of
the murmur
• You can utilize a towel to aid this
maneuver (pictured)

Accentuates the murmurs of mitral

regurgitation, aortic regurgitation
pulmonic stenosis, mitral stenosis and
ventricular septal defect
20
Special Maneuvers –
Transient Arterial Occlusion

• Note the patient’s blood pressure during vital sign assessment

• Position the patient in the supine position with HOB at 30 degrees
• Place your stethoscope where you hear the murmur the best /
loudest location
• Apply blood pressure cuffs to BOTH arms and inflate to 20 mmHg
greater than the peak systolic BP

Accentuates the murmurs of mitral regurgitation,

aortic regurgitation and ventricular septal defect

21
Murmur Clinic Cases
Using our brains and ears to identify
murmurs and underlying cardiac
conditions!
Diastolic Murmurs
“I’ve had this murmur for a long time, can
you tell me what it is?”
Brief Hx: 83-year-old male with PMH “murmur” MURMUR:
presents to your cardiology clinic for evaluation of the • Diastolic murmur
murmur.
• Location: heard best L 2nd – 4th ICS.
• Denies dyspnea on exertion (DOE), SOB at rest, PND, • Radiation: does not radiate
orthopnea.
• Timing: Early diastolic
Vitals: 98.2 (T), 95 (HR), 120/80 (BP), 14 (RR), 96% on
RA
• Shape: Decrescendo
• Intensity Grade: 3
Cardiac Exam:
• The JVP is 3 cm above the sternal angle with the HOB elevated to 30
• Pitch: High
degrees. Negative hepatojugular reflux. • Quality: Blowing (can be mistaken for breath
• Carotid upstrokes are brisk, without bruits. sounds)
• Crisp S1 and S2. • Maneuvers:
• Regular rate and rhythm. • Accentuated with patient sitting and leaning
• The PMI is tapping, 1 cm lateral to the midclavicular line in the 5th forward, holding breath after exhalation.
ICS. • Also with isometric handgrip, transient
• No heaves or thrills. arterial occlusion
• Diminished with Valsalva.
Aortic Regurgitation - Chronic
• Pathophys: CHRONIC aortic regurgitation is caused by a
bicuspid valve which occurs congenitally or aging of the
normal (tricuspid) aortic valve. The volume overload of
the left ventricle (LV) results in a gradual increase in
LV size that provides a normal forward cardiac output
despite the regurgitant valve flow; LV diastolic
pressures remain normal
• Symptoms: due to the chronicity and cardiac
compensation, patients can be asymptomatic until late
stage (stage 4) disease at which point they develop SOB,
DOE, PND, orthopnea or angina
• Physical Exam findings:
• Murmur as described on previous slide
• Corrigan pulse – A "water hammer" or "collapsing" pulse is characterized by a
rapidly rising and falling arterial pulse. This finding is best appreciated by
palpation of the radial or brachial arteries (exaggerated by raising the arm) or
the carotid pulses.
• Hill sign – Popliteal cuff systolic pressure exceeding brachial cuff pressure by https://www.uptodate.com/contents/images/CARD/77962/aorl
more than 20 mmHg with patient in the supine position (flat) lsbconv.mp4
• The most sensitive and specific sign for aortic regurgitation
• Late stage (Stage 4):
• PMI / apical impulse diffuse, displaced laterally and downward.
• A third heart sound (S3 gallop) is heard when LV function is severely
depressed
Aortic Regurgitation

Aortic Regurgitation Exam | Stanford Medicine 25 | Stanford Medicine

…Same murmur but presents acutely /
hemodynamically unstable
Brief Hx: 83-year-old male with PMH HTN presents to MURMUR:
your cardiology clinic for evaluation of acute onset DOE, • Diastolic murmur
SOB, PND, orthopnea.
• Location: heard best L 2nd – 4th ICS.
• Also has pain between shoulder blades
• Radiation: does not radiate
Vitals: 98.2 (T), 120 (HR), 85/40 (BP), 30 (RR), 80% on RA • Timing: Early diastolic
Cardiac Exam: • Shape: Decrescendo
• The JVP is 10 cm above the sternal angle with the HOB elevated to
30 degrees. Positive hepatojugular reflux. • Intensity Grade: 3
• Carotid upstrokes are brisk, without bruits. • Pitch: High
• Crisp S1 and S2. • Quality: Blowing (can be mistaken for
• Regular rate and rhythm. breath sounds)
• The PMI is tapping, 1 cm lateral to the midclavicular line in the 5th • Maneuvers:
ICS.
• Accentuated with patient sitting and leaning
• No heaves or thrills. forward, holding breath after exhalation.
Pulmonary Exam: • Also with isometric handgrip, transient
• Accessory muscle use, can only answer yes / no to questions arterial occlusion
• Rales in bases bilaterally • Diminished with Valsalva.
Aortic Regurgitation -
Acute
• Pathophys: ACUTE aortic regurgitation is caused most commonly by infective endocarditis or an
aortic dissection. The underlying pathophysiology depends on the underlying condition:
• In infective endocarditis, there is valve destruction and leaflet perforation leading to acute
aortic regurgitation
• In aortic dissection, the aortic regurgitation is a result of 4 mechanisms:
• Dilation of the sinuses with incomplete coaptation of the leaflets at the center of
the valve;
• Involvement of a valve commissure resulting in inadequate leaflet support
• Direct extension of the dissection into the base of a leaflet, resulting in a flail valve
leaflet
• Prolapse of the dissection flap across the aortic valve into the left ventricular
outflow tract in diastole impeding leaflet closure
• With acute AR, the regurgitant volume fills a small ventricle that has not had time to dilate,
resulting in an acute increase in LV diastolic pressure and a fall in forward cardiac output
• Symptoms: ACUTE onset SOB, DOE, chest pain (radiating to the back), upper back pain, PND, orthopnea
• Physical Exam findings:
• Murmur as described on previous slide
• Remainder of exam findings would be related to underlying cause (ie infective endocarditis or aortic
dissection)
“ I have fevers, I can’t breathe, and my legs
look like elephant legs!”
Brief Hx: 33-year-old female with PMH intravenous drug
use (IVDU) presents to your hospital with fevers, dyspnea
MURMUR:
on exertion and lower extremity edema. • Diastolic murmur
• She was clean until recently and starting using heroin
again. • Location: L 2nd and 3rd ICS
Vitals: 102.6 (T), 95 (HR), 120/80 (BP), 14 (RR), 96% on RA • Radiation:
Cardiac Exam: • Timing:
• The JVP is 8 cm above the sternal angle with the HOB
elevated to 30 degrees. • Shape: Diamond shaped
• Positive hepatojugular reflux. (crescendo-decrescendo)
• Carotid upstrokes are brisk, without bruits. • Intensity / Grade: 1-4
• Crisp S1 and S2.
• Regular rate and rhythm.
• Pitch: Can be high or low
• The PMI is tapping, 1 cm lateral to the midclavicular line in the • Quality: Blowing
5th ICS.
• Heave noted at the left sternal border and epigastric space
• Maneuvers:
• No thrills • Accentuated by inspiration
Pulmonic Regurgitation ** Not in Bates
• Pathophys: Pulmonic regurg can result from a variety of disorders most notably; pulmonary
hypertension and direct disease of the pulmonic valve. During systole, the ventricular pressures rise
to exceed the pressures in the pulmonary trunk / pulmonary artery. If the pressure is very high in the
pulmonary circulation (pulmonary hypertension), this can lead to backward flow of blood.
Alternatively, if there is a condition effecting the valve itself, this impairs its function / ability to close
completely and can lead to regurgitation.
• Symptoms:
• If the regurg is due to underlying pulmonary hypertension, the patient will have symptoms
related to the cause of the pHTN (COPD, asthma, OSA, OHS) – like SOB, DOE, cough.
• If the regurg is due to a condition impairing the valve function, patients more often present with
symptoms of right heart failure (elevated JVP, + hepatojugular reflux, lower extremity edema)
• Physical Exam findings:
• Murmur as per last slide
• Other PE findings will be related to underlying cause
“I keep waking up at night gasping for air!
What is going on! I don’t have sleep
apnea!!” MURMUR:
Brief Hx: 63-year-old male with PMH rheumatic heart disease as a
child presents to your office with PND and new 3 pillow
orthopnea. • Diastolic murmur
• States he has been ruled out for sleep apnea. • Location: heard best at the apex
Vitals: 98.8 (T), 90 (HR), 110/80 (BP), 14 (RR), 96% on RA • Radiation: none
Cardiac Exam: • Timing: Late diastolic
• The JVP is 3 cm above the sternal angle with the HOB elevated • Shape: Decrescendo with presystolic
to 30 degrees.
accentuation
• Negative hepatojugular reflux.
• Intensity / Grade: 1-4
• Carotid upstrokes are brisk, without bruits.
• Accentuated S1 and normal S2.
• Pitch: Low (heard best with the bell)
• Opening snap • Quality: Rumble
• Regular rate and rhythm. • Maneuvers:
• The PMI is tapping, 1 cm lateral to the midclavicular line in the • Accentuated with left lateral decubitus
5th ICS. and by exhalation.
• No heaves or thrills. • Also with isometric handgrip
Pulmonary Exam: • Diminished with standing to squatting
• Rales in both bases and during Valsalva release phase.
Cardiac Cycle and Heart Sounds

33
Mitral Stenosis
• Pathophys: narrowing of the mitral valve orifice most commonly results
from rheumatic heart disease wherein the streptococcal antigen cross
reacts with the valve tissue. The leaflets thicken and eventually fibrin
develops on the cusps leading to altered morphology and function. Left
atrial pressure increases eventually leading to increased pressure in the
pulmonary circulation.
• Symptoms:
• Orthopnea and PND
• Also: palpitations! (WHY??? – 30% of the time)
• Physical Exam Findings:
• Accentuated S1, opening snap and murmur per previous slide
• Murmur as per previous slide
• Apical impulse / PMI is small
Moving on to the Systolic
Murmurs
“I was talking to the kitchen table and next
thing I know; I woke up on the floor!”
Brief Hx: 75-year-old male with PMH hyperlipidemia and MURMUR:
rheumatic fever as a child presents to ER after a syncopal episode
• Has been having episodes of pre-syncope for the past few • Systolic murmur
weeks, this is the first true syncopal episode. Also complains
of worsening dyspnea on exertion as well as exertional chest
• Location: heard best R 2nd ICS.
pain. • Radiation: to carotids, down left
Vitals: 97.8 (T), 95 (HR), 110/80 (BP), 14 (RR), 96% on RA sternal border.
Cardiac Exam: • Timing: Mid-systolic
• The JVP is 3 cm above the sternal angle with the HOB elevated
to 30 degrees. Negative hepatojugular reflux. • Shape: Crescendo - Decrescendo
• Carotid upstrokes are delayed, slow rise, small amplitude. • Intensity / Grade: 4
• Crisp S1. S2 slightly diminished. • Pitch: Medium
• Regular rate and rhythm.
• The PMI is tapping, 1 cm lateral to the midclavicular line in the
• Quality: Harsh
5th ICS. • Maneuvers:
• No heaves. • Accentuated with patient sitting
• Thrill noted at R 2nd ICS and leaning forward, holding
breath after exhalation.
Aortic Stenosis
• Pathophys: stenosis of the aortic valve results from valve calcification in older
adults, congenital biscupid valve or rheumatic heart disease. The stenosis of
the valves causes turbulent blood flow and obstruction out of the aortic valve
leading to increased left ventricular systolic pressure and decreased aortic
pressure. Over time, this leads to LV mass and dysfunction / failure.
• Symptoms:
• Angina, syncope, dyspnea
• Physical exam findings:
• Carotid exam and systolic murmur as described on previous slide
• A2 may be delayed and merged with P2 leading to a single S2 on inspiration
• If advanced and patient has left sided heart failure at presentation, what physical
exam findings would you see?
 Cardiac Cycle and Heart Sounds – Splitting of S2

Assess for split S2

• S2 can have two

audible components
during inspiration
• A2: closure of aortic
valve
• P2: closure of
pulmonic valve Physiologic Splitting

http://www.easyauscultation.com/course-contents.aspx?CourseID=22
38
“I’ve been feeling really short of breath at
soccer practice and today I almost passed out”
Brief Hx: 23-year-old female without PMH presents MURMUR:
to ER with dyspnea on exertion and pre-syncope
• Systolic murmur
• Has been having episodes for months, now much
more pronounced. Has a family history of “heart • Location: heard best L 3rd and 4th ICS.
failure” in her mother and an aunt. • Radiation: down L sternal border to
Vitals: 97.8 (T), 95 (HR), 110/80 (BP), 14 (RR), 96% on apex. No radiation to the neck
RA • Timing: Mid-systolic
Cardiac Exam: • Shape: Crescendo - Decrescendo
• The JVP is 3 cm above the sternal angle with the • Intensity / Grade: 3
HOB elevated to 30 degrees. Negative • Pitch: Medium
hepatojugular reflux.
• Quality: Harsh
• Carotid upstrokes are brisk, without bruits. Maneuvers:
•
• Crisp S1 and S2. • Accentuated with squatting to
• S4 heard at the apex. standing and during strain phase of
• Regular rate and rhythm. Valsalva.
• The PMI is sustained, displaced laterally • Diminished with standing to
squatting and during Valsalva release
• No heaves or thrills. phase.
Hypertrophic Cardiomyopathy

• Pathophys: Hypertrophic cardiomyopathy (HCM) is a

genetic (autosomal dominant) heart muscle disease
caused by a mutation in sarcomere protein genes which
encodes for elements of the contractile machinery of the
heart. It is characterized by an increase in left ventricular
wall thickness (hypertrophy) which causes left
ventricular outflow obstruction, diastolic dysfunction,
myocardial ischemia, and mitral regurgitation.
• Symptoms: fatigue, dyspnea, chest pain, palpitations,
and syncope
• Can cause sudden cardiac death in teens and
young adults
• Physical exam findings:
• Murmur as outlined on previous slide
• + S4 as noted on previous slide
“I think I hear a systolic murmur” – PA-S on
Pediatric rotation
Brief Hx: 3-year-old female without PMH here for well MURMUR:
child visit when the Touro PA-S notes a murmur on
exam. • Systolic murmur
• Parents deny any symptoms • Location: heard best L 2nd and 3rd ICS.
Vitals: 97.8 (T), 110 (HR), 110/80 (BP), 20 (RR), 96% on • Radiation: None
RA (normal for the pediatric patient) • Timing: Mid-systolic
Cardiac Exam: • Shape: Crescendo - Decrescendo
• The JVP is 3 cm above the sternal angle with the • Intensity / Grade: Soft 1-2 (you are
HOB elevated to 30 degrees.
an expert clinician!)
• Negative hepatojugular reflux.
• Pitch: Medium
• Carotid upstrokes are brisk, without bruits.
• Crisp S1 and S2.
• Quality: Harsh
• Regular rate and rhythm. • Maneuvers:
• Sustained right ventricular impulse • Accentuated with isometric handgrip.
• No heaves or thrills.
Palpation of Precordium – Systolic
Impulse of the Right Ventricle

• Systolic impulse of RV
• Position the patient at a 30-degree angle and ask
the patient to exhale and stop breathing.
• Place the tips of your curved fingers in the 3rd, 4th
and 5th ICS.
• If there is a palpable impulse, assess its:
• Location
• Amplitude
• Duration
• Normal finding: no pulsation or a brief systolic tap
(in thin individuals)
• Abnormal finding: sustained parasternal
movement
• Associated conditions:
• Pulmonary hypertension
• Pulmonic stenosis
Pulmonic Stenosis
• Pathophys: Pulmonic stenosis is a defect of the pulmonic valve in
which the valve is stiffened, causing an obstruction to flow. This
disease is typically congenital, benign, and diagnosed in pediatric
patients.
• Symptoms: most of time asymptomatic
• If symptomatic, c/o dyspnea, fatigue
• Can be associated with atrial septal defect, if so, cyanotic
presentation at birth
• Physical exam findings:
• Systolic murmur outlined on previous slide
• Wide split of S2
• Can hear a right sided S4 over the left sternal border
Cardiac Cycle and Heart Sounds – Splitting of
S2
• Normal Finding: Right ventricular and pulmonary arterial
pressures are significantly lower than the pressures on the left
side, therefore right sided cardiac events occur slightly slower
than those on the left side. During inspiration, filling time on the
right side of the heart is increased. Therefore, the delayed
closure of the pulmonic valve (P2) causes two audible
components of S2 during inspiration – termed the split S2. They
should fuse into one sound during expiration.
• Abnormal Finding: Widened A2 and P2 or Fixed splitting
• Associated Conditions:
• Widened A2 and P2: Pulmonic stenosis, Right Bundle Branch Block
(RBBB)
• Fixed splitting: Atrial Septal Defect 45
… still in the Pediatric office
“Please come see the baby in room 3 now!
He is really struggling to breathe”
Brief Hx: 3-week-old male presents from
home with respiratory distress, increased
work of breathing and edema
• Parents state he is grunting, not eating.
Vitals: 97.8 (T), 160 (HR), 70/30 (BP), 60
(RR), 80% on RA
Cardiac Exam:
• Prominent apical impulse on inspection
• Apex / PMI displaced laterally, toward
the anterior axillary line
• Systolic murmur
• Location: L 3rd, 4th and 5th ICS
• Radiation: can be a wide area if the VSD is
large
• Timing: Pansystolic aka holosystolic
• Shape: Plateau
• Intensity / Grade: High, often associated
with a thrill
• *smaller defect = louder murmur!
• Pitch: High
• Quality: Harsh
• Maneuvers:
• Accentuated with isometric handgrip and
transient arterial occlusion.
Regurgitation through the AV valves

Tricuspid Regurgitation Murmur Mitral Regurgitation Murmur

• Systolic murmur • Systolic murmur
• Location: heard best L lower sternal • Location: heard best at the apex.
border. • Radiation: L axilla
• Radiation: to the right of the sternum and
to the epigastric / xiphoid area • Timing: Pansystolic aka holosystolic
• Timing: Pansystolic aka holosystolic • Shape: Plateau
• Shape: Plateau • Intensity / Grade: Variable
• Intensity / Grade: variable • Pitch: Medium to high
• Pitch: Medium • Quality: Blowing
• Quality: Blowing • Maneuvers:
• Maneuvers: • Accentuated with isometric handgrip.
• Accentuated with inspiration.
Auscultation – Murmurs
• Techniques - Heart Sounds & Murmurs Exam - Physical Diagnosis Skills
- University of Washington School of Medicine

• Demonstrations - Heart Sounds & Murmurs Exam - Physical Diagnosis

Skills - University of Washington School of Medicine
 Murmurs – Required Reading!!
• Review Bates Pgs 552 – 556
• Charts:
• 16-10
• 16-11
• 16-12
• 16-13
Useful Videos
Aortic Regurgitation – Stanford 25
https://stanfordmedicine25.stanford.edu/the25/aorticregurgitation.html

Second Heart Sounds – Stanford 25

https://stanfordmedicine25.stanford.edu/the25/cardiac.html

Diastolic Murmur Exam – Stanford25

https://stanfordmedicine25.stanford.edu/the25/DiastolicMurmursExam.html
General Murmur Video – Dr. Strong Stanford Medicine
https://www.youtube.com/watch?v=lFcf5a6BZGw
References
• Basit H, Brito D, Sharma S. Hypertrophic Cardiomyopathy. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430788/
• Levy D, Goyal A, Grigorova Y, et al. Aortic Dissection. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441963/
• Heaton J, Kyriakopoulos C. Pulmonic Stenosis. [Updated 2023 Jan 4]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560750/
• Levy D, Goyal A, Grigorova Y, et al. Aortic Dissection. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441963/
• Pendela VS, Ayyad R. Pulmonic Regurgitation. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553136/
• Pujari SH, Agasthi P. Aortic Stenosis. [Updated 2022 Dec 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557628/
• Shah SN, Sharma S. Mitral Stenosis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430742/