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Tricuspid and Pulmonary Valve Murmurs Explained TS TR PS PR Clinical Guide

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Frequently Asked Questions

What are right-sided heart murmurs?

Right-sided heart murmurs originate from the tricuspid or pulmonary valves and include tricuspid stenosis, tricuspid regurgitation, pulmonary stenosis, and pulmonary regurgitation. They characteristically become louder with inspiration due to increased venous return to the right heart.

Which murmurs increase in intensity with inspiration?

Tricuspid regurgitation, tricuspid stenosis, pulmonary stenosis, and pulmonary regurgitation typically increase with inspiration. This phenomenon is known as Carvallo sign and helps differentiate right-sided from left-sided murmurs.

What is the classic murmur of tricuspid regurgitation?

Tricuspid regurgitation produces a holosystolic murmur best heard at the left lower sternal border that becomes louder with inspiration and may be associated with prominent V waves in the jugular venous pulse.

How does tricuspid stenosis murmur differ from mitral stenosis murmur?

Tricuspid stenosis murmur is a low-pitched mid-diastolic murmur heard best at the left lower sternal border and increases with inspiration, whereas mitral stenosis is best heard at the apex and is louder during expiration.

What causes pulmonary stenosis murmur?

Pulmonary stenosis murmur is caused by obstruction to right ventricular outflow, producing an ejection systolic crescendo–decrescendo murmur at the left upper sternal border, often with an ejection click.

What is Graham Steell murmur?

Graham Steell murmur is a high-pitched early diastolic murmur of pulmonary regurgitation caused by severe pulmonary hypertension and is best heard at the left upper sternal border.

Which murmur is most commonly associated with intravenous drug use?

Tricuspid regurgitation is most commonly associated with intravenous drug use due to infective endocarditis affecting the tricuspid valve.

What jugular venous pulse finding is typical of tricuspid regurgitation?

Tricuspid regurgitation is associated with prominent V waves in the jugular venous pulse due to systolic backflow of blood into the right atrium.

What happens to presystolic accentuation in atrial fibrillation?

Presystolic accentuation disappears in atrial fibrillation because it depends on atrial contraction, which is absent in atrial fibrillation.

What is the definitive treatment for severe pulmonary regurgitation with right ventricular dilation?

Pulmonary valve replacement, either surgical or transcatheter, is the definitive treatment for severe pulmonary regurgitation associated with right ventricular dilation or dysfunction.

Which valve lesion is commonly associated with carcinoid syndrome?

Carcinoid syndrome most commonly affects the tricuspid valve, leading to tricuspid regurgitation due to fibrotic plaque deposition.

How can tricuspid regurgitation be differentiated from ventricular septal defect on auscultation?

Tricuspid regurgitation murmur increases with inspiration, whereas the murmur of ventricular septal defect does not show inspiratory augmentation.

Which murmur is common after repair of Tetralogy of Fallot?

Pulmonary regurgitation is common after Tetralogy of Fallot repair and presents as an early diastolic decrescendo murmur at the left upper sternal border.

What is the most common cause of tricuspid stenosis worldwide?

Rheumatic heart disease is the most common cause of tricuspid stenosis worldwide, often occurring in association with mitral stenosis.

Why are diastolic murmurs considered pathological?

Diastolic murmurs almost always indicate structural heart disease because normal blood flow during diastole does not usually produce audible turbulence.

MCQ Test - Tricuspid and Pulmonary Valve Murmurs Explained TS TR PS PR Clinical Guide

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1 A 46-year-old woman with long-standing rheumatic heart disease presents with fatigue, abdominal distension, and pedal edema. Examination shows a prominent a-wave in JVP and a low-pitched mid-diastolic murmur at the left lower sternal border that increases with inspiration. What is the most likely diagnosis?

Explanation:

A mid-diastolic murmur at the left lower sternal border with inspiratory augmentation and prominent a-waves is characteristic of tricuspid stenosis.

2 A 58-year-old man with dilated cardiomyopathy presents with worsening edema and hepatomegaly. A holosystolic murmur at the left lower sternal border becomes louder during inspiration. Which jugular venous pulse finding is most likely?

Explanation:

Tricuspid regurgitation causes systolic backflow into the right atrium, producing prominent v-waves in the JVP.

3 An intravenous drug user presents with fever and a new cardiac murmur. A harsh holosystolic murmur is heard at the left lower sternal border with inspiratory accentuation. Which valve is most likely involved?

Explanation:

IV drug use most commonly causes infective endocarditis of the tricuspid valve, leading to tricuspid regurgitation.

4 A 22-year-old woman presents with exertional dyspnea. Examination reveals an ejection systolic murmur at the left upper sternal border with an ejection click that softens on inspiration. What is the diagnosis?

Explanation:

Pulmonary stenosis produces an ejection systolic murmur at LUSB with an ejection click that decreases with inspiration.

5 A patient with Noonan syndrome presents with exertional syncope and a systolic murmur at the left upper sternal border. What is the primary hemodynamic abnormality?

Explanation:

Pulmonary stenosis causes right ventricular outflow tract obstruction and is commonly associated with Noonan syndrome.

6 A patient with severe pulmonary hypertension develops a high-pitched early diastolic murmur at the left upper sternal border beginning immediately after P2. This murmur is called?

Explanation:

Graham Steell murmur is a high-pitched early diastolic murmur of pulmonary regurgitation due to pulmonary hypertension.

7 A 30-year-old patient status post Tetralogy of Fallot repair presents with declining exercise tolerance. A decrescendo early diastolic murmur is heard at the left upper sternal border. What is the most likely cause?

Explanation:

Chronic pulmonary regurgitation is a common late complication after TOF repair.

8 A diastolic murmur at the left lower sternal border shows presystolic accentuation that disappears when the patient develops atrial fibrillation. Which lesion is responsible?

Explanation:

Presystolic accentuation depends on atrial contraction and is seen in tricuspid stenosis; it disappears in atrial fibrillation.

9 A patient has giant v-waves in the jugular venous pulse and a systolic murmur increasing with inspiration. What is the underlying mechanism?

Explanation:

In tricuspid regurgitation, systolic backflow into the right atrium causes prominent v-waves.

10 A systolic murmur at the left upper sternal border becomes louder immediately after release of the Valsalva maneuver. Which diagnosis best fits?

Explanation:

Pulmonary stenosis murmur increases with increased venous return after Valsalva release.

11 A patient with carcinoid syndrome develops signs of right-sided heart failure and a new murmur. Which valvular lesion is most characteristic?

Explanation:

Carcinoid heart disease preferentially affects right-sided valves, especially causing tricuspid regurgitation.

12 A low-pitched diastolic murmur at the xiphoid area increases with inspiration. Which maneuver will reduce its intensity?

Explanation:

Standing reduces venous return and decreases the intensity of right-sided murmurs such as tricuspid stenosis.

13 A patient with severe pulmonary regurgitation shows progressive right ventricular dilation on imaging. What is the most appropriate definitive treatment?

Explanation:

Severe pulmonary regurgitation with RV dilation requires pulmonary valve replacement to prevent RV failure.

14 A holosystolic murmur at the left lower sternal border does not radiate and increases with inspiration. Which feature best differentiates it from a ventricular septal defect?

Explanation:

Inspiratory augmentation (Carvallo sign) helps distinguish tricuspid regurgitation from VSD.

15 A patient has wide splitting of S2 with delayed P2 and an ejection systolic murmur at the left upper sternal border. What is the most likely diagnosis?

Explanation:

Pulmonary stenosis causes delayed P2 and wide splitting of S2 with an ejection systolic murmur at LUSB.

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