Cardiac murmurs and valvular disorders

Question 1

loud first heart S1 sound and opening snap heard after S2 near the apex, diastolic rumble at the cardiac apex

Answer 1

mitral stenosis

Question 2

early diastolic murmur best heard at the left sternal border

Answer 2

aortic regurgitation

Question 3

holosystolic murmur best heard along the left sternal border that increases with inspiration

Answer 3

tricuspid regurgitation

Question 4

pulsatile neck veins and prominent C V wave on jugular venous pulsation

Answer 4

pulmonary hypertension and tricuspid regurgitation

Question 5

loud holosystolic murmur with palpable trill and best heard over the 3 and 4th left intercostal space

Answer 5

VSD - holosystolic murmur, high pitched and without respiratory variation.

different from aortic stenosis based on location and nature

not the same as HOCM because the murmur changes in preload.

no need for repair of small VSDs

Question 6

ebstein’s anormaly

Answer 6

tricuspid valve and right ventircle is misshapened and so see tricuspid regurgig and 1st and 2nd heart sounds are widely split due to RBBB

Question 7

normal prengnacy physiological changes result in

Answer 7

increased blood flow and cardiac output can cause a short and soft systolic ejection murmur due to increased flow across the normal aortic pulmonary valves

Question 8

mitral stenosis murmur

Answer 8

low pitched diastolic rumble heard at the apex, as stenosis becomes more severe opening snap happens earlier than S2 (shorter A2-OS interval).

Question 9

all left sided murmurs (mitral and aortic)

Answer 9

increase on expiration so that rules out right sided murmurs pulmonary and tricuspid.

Question 10

auscultation of cardiac murmurs with maneuver and what it does

Answer 10

Question 11

maneuvers that decrease LV volume

Answer 11

valsalva and standing

Question 12

maneuvers that increase LV filling or volume

Answer 12

squatting and leg raise.

Question 13

what happens to fixed obstructions if there’s less venous return

Answer 13

less flow across obstruction so will decrease murmur.

Example aortic stenosis will have decreased murmur with valsalva and standing.

Question 14

that happens to HCM or MVP when there’s less venous return (standing or valsalva)?

Answer 14

there’s less LV filling and less venous return which means that there is less blood flow to prevent obstruction or full inflation of mitral valve so the murmurs of HCM and MVP will worsen.

Question 15

mitral valve prolapse prevalence

Answer 15

2-3% of population but higher prevalence in women

Question 16

most common cause of mitral regurgitation

Answer 16

mitral valve prolapse. but most pts with MVP have mild MR with only severe MR in <5% of pts.

Question 17

most complications from mitral valve prolapse is

Answer 17

cardiac arrhythmias (atrial or ventricular premature beats, ventricular or SVT)

worsening MR

CHF, infective endocarditis and TIA and stroke

Question 18

does mitral valve prolapse pts have greater cardiovascular morbidity or mortality?

Answer 18

no, have the same as general population except

moderate to severe MR and LVEF<50% will have increased risk for adverse cardiac events.

Other RF for worse cardiac morbidity is LA size >40 mm, flail mitral leaflet and afib and age>50 yrs

Question 19

short systolic murmur at left sternal border and cardiac apex that gets longer with standing

Answer 19

mitral valve prolapse with mitral regurgitation

MVP shows single or multiple non ejection clicks - from snapping of mitral chordae during systole

mid to late systolic murmur with mitral regurg

Question 20

what maneuvers decrease venous return

decrease LV volume and cavity size

Answer 20

valsalva manuever

standing from supine position

Question 21

maneuvers that increase LV filling, and improve closure of mitral leaflets and delay the click of MVP and soften murmur

Answer 21

Squatting

leg raise

Question 22

standing and valsalva maneuvers cause MVP murmur and click to change how?

Answer 22

earlier and systolic click and longer murmur (due to decreased venous return and LV volume)

Question 23

squatting and leg elevation can cause what changes to click and murmur of MVP?

Answer 23

causes delayed systolic click and shorter murmur (due to increased LV volume)

Question 24

how to manage chronic mitral regurgitation

Answer 24

only recommend mitral valve surgery for asymptomatic pts who have:

EF <60%

EF >60% and new onset afib

EF >60% and new onset of pulmonary HTN

Don’t pick mitral valve surgery for pts who have mitral regurgitation secondary to dialted ischeic cardiomyopathy - need heart failure tx

Question 25

Asymptomatic chronic mitral regurgitation pts need

Answer 25

serial monitoring as long as there’s no new pulmonary HTN, afib, heart failure or EF<60% can continue to get routine TTE every 6 to 12 months.

Question 26

Does mitral valve prolapse need prophylactic abx prior to dental work?

Answer 26

no.

Question 27

chronic severe mitral regurgitation requires intervention with:

Answer 27

develop symptoms (SOB, chest pain)

TTE: EF<60% or end systolic is >4mm),

or pulmonary HTN>50 mmHg

new onset afib.

prefer mitral valve repair over replacement.

Question 28

antibiotic prophylaxis is only for:

Answer 28

• pts with valvular heart disease that has been repaired with prosthetic valve or prosthetic material (mitral or tricuspid ring)
• hx of prior endocarditis
• congenital heart dx (unrepaired cyanotic, or within 6 months of repaired congenital heart dx, or repaired congenital heart dx with residual deficits)
• cardiac transplant with abnormal valve or regurgitation.

Question 29

Pulmonic stenosis

Answer 29

ejection systolic click with associated systolic ejection murmur that is best heard over the left second intercostal space with radiation to the left neck

Question 30

mitral stenosis

Answer 30

Mitral stenosis has an opening snap of the mitral valve and a low pitched rumbling murmur heard throughout diastole.

best heard when pt is in the LEFT LATERAL DECUBITIS POSITION with stethoscope at the bell of the cardiac apex.

Question 31

mitral valve prolapse

Answer 31

single or multiple mid systolic click and mid to late systolic murmur of mitral regurgitation.

Standing and valsalva cause earlier systolic click and longer murmur (decreased LV volume)

squatting or leg elevation causes delayed systolic click and shorter murmur (due to increased left ventricular size and volume).

Question 32

aortic regurgitation

Answer 32

aortic regurgitation leads to early descrendo diastolic murmur that begins immediately after A2 (aortic component of S2) and ends prior to start of S1.

Murmur is high pitched and blowing in quality and best heard along the l_eft sternal border of 3rd and 4 intercostal_.

Some breath sounds can completely obscure the murmur in pts. As a result it’s better for pt to lean forward and hold their breath in full expiration.

Question 33

Aortic stenosis criteria and time for follow up chart

Answer 33

Progression of AS is variable; aortic valve area declines at average rate of 0.1 cm2/year in most pts.

Question 34

who gets bacterial prophylaxis for endocarditis?

the high risk cardiac conditions

the type of procedures and the antibiotic coverage.

Answer 34

Question 35

Ventricular septal defect management

MTV: holosytolic murmurs.

Answer 35

VSD- holosystolic murmur with maximal intensity is over 3rd or 4th left intercostal space along the left sternal border and accompanied by a systolic thrill.

For small VSD- observation would be best as 10% of them close up as adults.

If pt develops volume overload or left ventricular dilation they have an increased risk for endocarditis.

Surgery is needed for those who develop any of these complications and significant Eisenmenger syndrome.

Question 36

S3 can be heard in

Answer 36

healthy young adults and may not be a sign of anything.

S4 can be heard in older adults due to decreased ventricular compliance with age. S4 in young adults can signify abnormality

if there’s a S3 >40 yrs, its is abnormal and suggests enlargement of the ventricular chambers - severe mitral regurg, chronic aortic regurgitation and heart failure associated with dilated cardiomyopathy and in high cardiac output states and pregnancy and thyroxicosis.

Question 37

indications for percutaneous mitral balloon valvotomy

Answer 37

when someone has symptomatic mitral stenosis and needs further therapy to relieve obstrution to prevent long term complications

Options for treatment: percutaneous mitral balloon valvotomy (PMBV) and surgical commissurotomy

decision to do it is based on:

valve morphology,

degree of mitral regurgitation,

presence of or absence of contraindications to PMBV.

Mitral valvotomy is preferred approach in all pts who have suitable valvular morphology and mitral stenosis

• contraindicated in moderate or severe degree of mitral regurgitation.

Question 38

when do you replace a mitral valve with mitral balloon valvotomy?

Answer 38

symptomatic rheumatic MS

asymptomatic pts who have good morphology of valve

moderate to severe MS valve area <1.5 cm and pulm HTN with rest or exercise

palliation in non surgical pts

Can’t do it in

atrial or left appendage thrombus

moderate to severe mitral regurg.

Question 39

comparison of aortic regurg and aortic stenosis

Answer 39

AS murmur increases with squatting because of less preload. AS is systolic murmur.

Question 40

apical displacement of tricuspid valve leaflets and see decreased volume of hte right ventricule and atrialization of the right ventricle. Seen with tricuspid regurgitation and results in a holosystolic murmur over the third intercostal space or at the subxiphoid area.

Answer 40

This is an Ebstein anomaly seen with tricuspid regurgitation.

Question 41

when do we hear a pericardial knock?

Answer 41

earlier than normal S3 that occurs due to restricted ventricular filling during diastole

seen in constrictive pericarditis

Question 42

pulmonic stenosis facts

Answer 42

a childhood dx when severe or moderate

when present as an adult it’s with mild to moderate dx and symptoms are shortness of breath with exertion and syncope and angina or right sided heart failure symptoms such as peripheral edema

Question 43

indications for treatment of pulmonic stenosis

Answer 43

severe pulmonic stenosis

mean gradient >30 mm Hg or peak gradient >50 mm Hg (severe stenosis)

absence of symptoms but mean gradient >40 mm HG or peak gradient >60 mmHg

Treat with balloon valvotomy if valve is domed and not dysplastic

surgical intervention is meant for dysplastic valves, hypoplastic pulmonary annulus, subvalvular stenosis or supravalvular stenosis.

Question 44

mitral regurgitation and EF

Answer 44

note that amount of volume that flows into the left atrium during systole due to the incompetent valve can overestimate EF and a pt’s true systolic function

this is why we treat with mitral valve r_epair for mitral regurgitation in pts who have_

EF<60

EF>60 but have afib

EF >60 but have pulmonary HTN

Question 45

in chronic primary mitral regurgitation which is severe and symptomatic why do we prefer mitral valve repair over mitral valve replacement?

Answer 45

mitral valve repair is better than mitral valve replacement because

1. mitral valve repair is performed at lower operative mortality when compared to mitral valve replacement.
2. LV function is preserved better following repaire because it preserves the intergrity of the mitral valve apparatus
3. repaire avoids risks inherent with prosthetic heart vavles - VTE and AC hemorrahge for mechnical heart valves or structural deterioration of bioprosthetic valves

Question 46

late complication of VSD as an adult with large VSD?

Answer 46

see Eisenmenger syndrome with R to L flow as well as pulmonary HTN.

VSD murmur is holosystolic high pithed and without respiratory variation and its murmur is not affected by different maneuvers.

Question 47

pt has pulmonary hypertension (>50 mmHg at rest >60 mm Hg with exercise) and has moderate to severe mitral stenosis. What to do next?

Answer 47

need to get mitral valvotomy in asymptomatic pts who have moderate to severe MS + development of pulmonary HTN

they need favorable valve morphology

absence of left atrial thrombosis.