Murmurs with High Pressure in the Pulmonary Artery Graham Steell Murmur

1. How high does the pulmonary artery pressure have to be to produce a pulmonary regurgitation (PR) murmur?

ANS: It is usually at nearly systemic levels. Pulmonary regurgitation murmurs are rarely present with pulmonary artery pressures of below 80 mmHg systolic unless the main pulmonary artery is markedly dilated.

Note: A Graham Steell murmur is a PR murmur that is secondary to pulmonary hypertension.

2. How does the Graham Steell murmur differ from the AR murmur?

ANS: It may not differ, i.e., both are dominantly high-pitched and may be from grade l to 6. The Graham Steell murmur, however, often increases with inspiration and also increases with amyl nitrate, while AR decreases.

These phonocardiograms are from a patient with a PDA whose pulmonary artery pressure was 145 mmHg, with an aortic pressure about the same. This loud dias-tolic murmur (Graham Steell murmur) increased markedly on inspiration. A soft Graham Steell murmur may not increase with inspiration.

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