Cardiac murmurs and valvular disorders Flashcards
loud first heart S1 sound and opening snap heard after S2 near the apex, diastolic rumble at the cardiac apex
mitral stenosis
early diastolic murmur best heard at the left sternal border
aortic regurgitation
holosystolic murmur best heard along the left sternal border that increases with inspiration
tricuspid regurgitation
pulsatile neck veins and prominent C V wave on jugular venous pulsation
pulmonary hypertension and tricuspid regurgitation
loud holosystolic murmur with palpable trill and best heard over the 3 and 4th left intercostal space
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
ebstein’s anormaly
tricuspid valve and right ventircle is misshapened and so see tricuspid regurgig and 1st and 2nd heart sounds are widely split due to RBBB
normal prengnacy physiological changes result in
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
mitral stenosis murmur
low pitched diastolic rumble heard at the apex, as stenosis becomes more severe opening snap happens earlier than S2 (shorter A2-OS interval).
all left sided murmurs (mitral and aortic)
increase on expiration so that rules out right sided murmurs pulmonary and tricuspid.
auscultation of cardiac murmurs with maneuver and what it does
maneuvers that decrease LV volume
valsalva and standing
maneuvers that increase LV filling or volume
squatting and leg raise.
what happens to fixed obstructions if there’s less venous return
less flow across obstruction so will decrease murmur.
Example aortic stenosis will have decreased murmur with valsalva and standing.
that happens to HCM or MVP when there’s less venous return (standing or valsalva)?
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.
mitral valve prolapse prevalence
2-3% of population but higher prevalence in women
most common cause of mitral regurgitation
mitral valve prolapse. but most pts with MVP have mild MR with only severe MR in <5% of pts.
most complications from mitral valve prolapse is
cardiac arrhythmias (atrial or ventricular premature beats, ventricular or SVT)
worsening MR
CHF, infective endocarditis and TIA and stroke
does mitral valve prolapse pts have greater cardiovascular morbidity or mortality?
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
short systolic murmur at left sternal border and cardiac apex that gets longer with standing
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
what maneuvers decrease venous return
decrease LV volume and cavity size
valsalva manuever
standing from supine position
maneuvers that increase LV filling, and improve closure of mitral leaflets and delay the click of MVP and soften murmur
Squatting
leg raise
standing and valsalva maneuvers cause MVP murmur and click to change how?
earlier and systolic click and longer murmur (due to decreased venous return and LV volume)
squatting and leg elevation can cause what changes to click and murmur of MVP?
causes delayed systolic click and shorter murmur (due to increased LV volume)
how to manage chronic mitral regurgitation
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
Asymptomatic chronic mitral regurgitation pts need
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.
Does mitral valve prolapse need prophylactic abx prior to dental work?
no.
chronic severe mitral regurgitation requires intervention with:
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.
antibiotic prophylaxis is only for:
- 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.
Pulmonic stenosis
ejection systolic click with associated systolic ejection murmur that is best heard over the left second intercostal space with radiation to the left neck
mitral stenosis
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.
mitral valve prolapse
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).
aortic regurgitation
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.
Aortic stenosis criteria and time for follow up chart
Progression of AS is variable; aortic valve area declines at average rate of 0.1 cm2/year in most pts.
who gets bacterial prophylaxis for endocarditis?
the high risk cardiac conditions
the type of procedures and the antibiotic coverage.
Ventricular septal defect management
MTV: holosytolic murmurs.
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.
S3 can be heard in
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.
indications for percutaneous mitral balloon valvotomy
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.
when do you replace a mitral valve with mitral balloon valvotomy?
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.
comparison of aortic regurg and aortic stenosis
AS murmur increases with squatting because of less preload. AS is systolic murmur.
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.
This is an Ebstein anomaly seen with tricuspid regurgitation.
when do we hear a pericardial knock?
earlier than normal S3 that occurs due to restricted ventricular filling during diastole
seen in constrictive pericarditis
pulmonic stenosis facts
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
indications for treatment of pulmonic stenosis
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.
mitral regurgitation and EF
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
in chronic primary mitral regurgitation which is severe and symptomatic why do we prefer mitral valve repair over mitral valve replacement?
mitral valve repair is better than mitral valve replacement because
- mitral valve repair is performed at lower operative mortality when compared to mitral valve replacement.
- LV function is preserved better following repaire because it preserves the intergrity of the mitral valve apparatus
- repaire avoids risks inherent with prosthetic heart vavles - VTE and AC hemorrahge for mechnical heart valves or structural deterioration of bioprosthetic valves
late complication of VSD as an adult with large VSD?
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.
pt has pulmonary hypertension (>50 mmHg at rest >60 mm Hg with exercise) and has moderate to severe mitral stenosis. What to do next?
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.
