Graham steell noise

On March 7, 1888, Graham Steell (1851 - 1942) gave a lecture in Manchester on "The auscultatory signs of mitral obstruction and insufficiency" and presented an auscultatory early diastolic murmur caused by pulmonary hypertension, which was later named after him (Fraser 1991).

Austin Flint (1812 - 1886), a New York internist, suggested the mechanism of origin of a particular murmur by aortic valve insufficiency as early as the mid-19th century . This sound was then named after him as the Austin Flint sound (Gahl 2014).

A Graham- Steell murmur is the characteristic of pulmonary valve regurgitation in pulmonary hypertension of a high-frequency early diastolic decrescendo murmur following the pulmonary segment of the 2nd heart sound during diastole (Herold 2022 / Dennis 2019).

Auscultation:

The Graham- Steell sound begins immediately after the pulmonary valve closure sound (Erdmann 2006).

It is auscultated at the left sternal border with punctum maximum in the 2nd or 3rd ICR, the auscultation point of the pulmonary valve (Riecker 1993) as a loud S 2 (Mewis 2006). The loudness may increase during inspiration and is usually associated with a loud, sometimes even palpable P2 (Kasper 2015). It is also more clearly audible after physical exertion (Riecker 1993).

A Graham- Steell murmur may occur in the setting of:

- pulmonary valve insufficiency

- pulmonary regurgitation (dilatation of the valve annulus due to increased pulmonary artery pressure)

- severe pulmonary hypertension (Kasper 2015)

- relative pulmonary valve regurgitation due to atrial septal defect (Riecker 1993)

The murmur results from the fact that during diastole the reverse pressure gradient between the truncus pulmonalis and the right ventricle decreases (Riecker 1993).

- Sound of aortic valve regurgitation (Kasper 2015). This is similar to the Graham- Steell sound in both frequency and loudness (Mewis (2006).

1. Dennis M, Bowen W T, Cho L (2019) Clinical practice: understanding symptoms - interpreting clinical signs. Elsevier Urban and Fischer Publishers Germany 144
2. Erdmann E (2006) Clinical cardiology: diseases of the heart, circulation, and cardiac vessels. Springer Medizin Verlag Heidelberg 735
3. Fraser A G, Weston C F M (1991) The Graham Steell murmur: eponymous serendipity? Coll Physicians Lond. 25 (1) 66 - 70
4. Gahl K, Holldack K (2014) Auscultation and percussion - inspection and palpation. Georg Thieme Verlag Stuttgart / New York 156
5. Herold G et al (2022) Internal medicine. Herold Publishers 180
6. Kasper D L, Fauci A S, Hauser S L, Longo D L, Jameson J L, Loscalzo J et al (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education 51 e- 5, 51 e- 6, 1540, 1550.
7. Mewis C, Riessen R, Spyridopoulos I (2006) Cardiology compact: everything for ward and specialist examination. Georg Thieme Verlag Stuttgart / New York 30, 32
8. Riecker G, Autenrieth G, Bolte H D, Erdmann E, Hort W, Steinbeck G, Strauer B E (1993) Diseases of the heart, circulation, and vessels near the heart. Springer Verlag Berlin / Heidelberg 30, 248, 255, 310 - 314