Differentiating Pulmonic Insufficiency from Aortic Insufficiency by Auscultation

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The diastolic murmurs of pulmonic insufficiency and aortic insufficiency may not be easy to distinguish by auscultation alone. This is especially true if the pulmonic insufficiency is moderate to severe and the aortic insufficiency is not chronic enough, or severe enough to generate the dramatic diagnostic physical findings of chronic severe aortic insufficiency.

Prior to the availability of echocardiography, mitral stenosis patients with (what was thought to be) pulmonic insufficiency sometimes underwent mitral commissurotomy with unfavorable hemodynamic results because the murmur of pulmonic insufficiency turned out to be a murmur of aortic insufficiency.

Once the mitral stenosis was relieved, the aortic insufficiency actually got worse, and the patient deteriorated clinically.

Patients with significant aortic insufficiency will have their murmur accompanied by prominent physical findings; yet, in patients with mitral stenosis, these physical findings may be absent because of the relatively low volume of aortic insufficiency. Furthermore, although the physical findings are prominent, they may not be prominent in every patient beacuse of different body habitus.

Patients with mitral valve disease and accompanying aortic valve disease may have auscultatory findings that wrongly suggest that the murmur is pulmonic in nature. Specifically, the pulmonic component of the second heart sound may be increased in mitral stenosis. When the examiner hears a diastolic murmur in addition to the increased pulmonic component, the logical (alas, mistaken) conclusion would be that this is the Graham Steell murmur of pulmonic insufficiency.

Using the location of the murmur may sometimes mislead as well. Although aortic insufficiency may be better heard at the upper right sternal border, that is not necessarily always the case. In addition, although it is not supposed to, the murmur of pulmonic insufficiency may not stay confined to the left sternal border and may confound the diagnosis by radiating to the right sternal border.

Therefore, simply using auscultation, one may not make the right differential diagnosis.

With the availability of echocardiography, this is no longer an issue, and one simply needs to incorporate the physical findings together with the echocardiographic evaluation, and with the clinical presentation of the patient.

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