Auscultation in Tetralogy of Fallot
The cardiac impulse is best palpated at the lower left sternal border.
There is a single second heart sound at the upper left sternal border.
This single second heart sound may be louder than normal.
This second heart sound becomes more audible lower down the left sternal border (indicating
the aortic origin): louder at the third and fourth interspace than at the second
The systolic murmur is determined by the nature and degree of right
ventricular outflow obstruction. It does not originate at the non-restrictive ventricular septal defect.
Decreasing systemic vascular resistance with amyl nitrite inhalation will make the systolic murmur
shorter and softer.
The tetralogy systolic murmur peaks earlier than the murmur of pulmonic valve stenosis with intact ventricular
The tetralogy systolic murmur has less crescendo-decrescendo quality compared to the murmur
of pulmonic valve stenosis with intact ventricular septum.
In contrast to severe valvular pulmonic stenosis, the systolic murmur of tetralogy does not
obscure the aortic second sound.
The systolic murmur behaves in opposite fashion in the following two conditions as the
severity of stenosis increases. In worsening valvular pulmonic stenosis with intact ventricular
septum - the murmur becomes louder, longer and later-peaking. In worsening tetralogy - the murmur
becomes softer, shorter and earlier-peaking.
A systolic murmur is usually absent in tetralogy when there is pulmonary atresia rather
than pulmonic stenosis.
A machinery murmur peaking at the second heart sound (from a patent
ductus arteriosus) may be heard when there is pulmonary atresia.
A to-and-fro murmur in the paravertebral area is due to collateral
flow in the bronchial arteries.
A loud, early-systolic aortic ejection sound is almost invariably present in tetralogy when
there is pulmonary atresia (rather than pulmonic stenosis).
Tetralogy with pulmonary atresia may have similar auscultatory findings to other cyanotic heart diseases
that develop severe pulmonary hypertension and Eisenmenger physiology.
Both groups may have a short early-systolic murmur.
Both groups may have a loud unsplit second heart sound.
Both groups may have a loud early-systolic ejection click, but the origin of the click is different .
The tetralogy click is aortic (not pulmonic), and does not vary with respiration.
A pulmonic ejection click gets louder on expiration.
Unforunately, any heart sound (including an aortic ejection click) may get more audible in expiration
for the simple reason that there is less lung tissue between the stethoscope and the source of the click.
J Thorac Cardiovasc Surg. 1973 Oct;66(4):658-61.
Mitral insufficiency associated with Fallot's tetralogy. Complete surgical correction.
De Salamanca FE, De Artaza M, Judez M, Tellex G, Figuera D
Br Heart J. 1973 Apr;35(4):402-12.
Genesis, frequency, and diagnostic significance of ejection sound in adults with tetralogy of Fallot.
Martin CE, Reddy PS, Leon DF, Shaver JA.
Arch Inst Cardiol Mex. 1972 Nov-Dec;42(6):875-9.
Variations of the pulmonary systolic murmur and the carotid pulse in Fallot's tetralogy
Esplugas Oliveras E, Freixa Taxonera E, Simon Lamuela J, Huerta Llorente F.
Dan Med Bull. 1971 Jan;18:Suppl 2:49-53.
Auscultation and intracardiac phonocardiography in patients with Tetralogy of Fallot.
Scand J Thorac Cardiovasc Surg. 1968;2(2):96-8.
The interpretation of intracardiac phonocardiography of a continuous murmur developed after radical operation for tetralogy of Fallot.
Wennevold A, Rygg IH.
Minerva Cardioangiol. 1967 Nov;15(11):707-12.
The importance of the auscultation and phonocardiographic patterns in the quantification of pure pulmonary stenosis and tetralogy of Fallot.
Marsico F, Boccalatte A, Forni N, Ricciardi A.
Minerva Cardioangiol. 1967 Aug;15(8):531-5.
Methoxamine and amyl nitrite in the differential diagnosis of pure pulmonary stenosis and acyanotic tetralogy of Fallot.
Boccalatte A, Forni N, Ricciardi A.
Cardiovasc Res Cent Bull. 1967 Jul-Sep;6(1):24-32. Related Articles, Links
The second heart sound in tetralogy of Fallot and its importance in the evaluation of results of surgical corrective procedures.
Leachman RD, Wilcox RB.
The aortic and pulmonary components of the second heart sound in mitral stenosis, atrial septal defect and tetralogy of Fallot.
Am J Cardiol. 1966 Dec;18(6):821-6.
Continuous murmurs in tetralogy of Fallot and pulmonary atresia with ventricular septal defect.
Ongley PA, Rahimtoola SH, Kincaid OW, Kirklin JW.
Am Heart J 57:803, 1959
The value of amyl nitrite in the differentiation of Fallot's tetralogy and pulmonary stenosis
with intact ventricular septum.
Vogelpoel L, Schrire V, Nellen M, Swanepoel A.
Circulation. 1955 May;11(5):714-32.
The role of auscultation in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact ventricular septum and right-to-left interatrial shunt.
Vogelpoel L, Schrire V.
Back to E-chocardiography Home Page.
The contents and links on this page were last verified on
June 28, 2006.