Heart Murmurs and Valvular Disease

Question 1

aortic stenosis

Answer 1

systolic: between S1 and S2
crescendo-decrescendo
LV» aortic pressure in systole: causes concentric LVH
loudest: base, radiates to carotids
pulse weak with delayed peak
Sx: syncope, angina, dyspnea on exertion( HF), arrhythmia, sudden death
Cause: calcification of valve (usually age related or early onset in bicuspid aortic valve)

Question 2

mitral regurgitation

Answer 2

systolic: between S1 and S2
holosystolic, high-pitched blowing
loudest: apex to axilla
cause: ischemic heart disease (post-MI), MVP, LV dilation; rheumatic fever, infective endocarditis

Question 3

tricuspid regurgitation

Answer 3

systolic: between S1 and S2
holosystolic, high-pitched blowing
loudest: tricuspid area to right sternal border
cause: RV dilation; rheumatic fever, infective endocarditis

Question 4

mitral valve prolapse

Answer 4

MOST COMMON
systolic: start halfway between S1 and S2 (end)
mid systolic click with late crescendo murmur
loudest: apex (just before S2)
predisposes to infective endocarditis
causes: myxomatous degeneration (Marfan or Ehlers-Danlos), rheumatic fever, chordae rupture
thinned zona fibrosa, expanded zona spongiosa
pregnancy: regurgitation goes into remission due to increased blood volume
rare complication: infective endocarditis

Question 5

ventricular septal defect

Answer 5

systolic: between S1 and S2
holosystolic, harsh
loudest: tricuspid

Question 6

aortic regurgitation

Answer 6

diastolic: after S2
high-pitched blowing early diastolic (long diastolic murmur and hyper dynamic pulse: severe and chronic)
get eccentric hypertrophy
cause: aortic root dilation, bicuspid aortic valve, endocarditis, rheumatic fever
progresses to left HF
Sx: pistol shot, head bobbing, wide PP

Question 7

patent ductus arteriosus

Answer 7

continuous

loudest: left infraclavicular area at S2
causes: rubella, premature

Question 8

mitral stenosis

Answer 8

diastolic: after S2
opening snap, delayed rumbling late diastolic murmur
LA» LV pressure in diastole
severity increases as interval between S2 and opening snap decreases
cause: rheumatic fever
can progress to LA dilation, RHF

Question 9

S1

Answer 9

mitral and tricuspid close

loudest: at mitral

Question 10

S2

Answer 10

aortic and pulmonary close

loudest: left upper sternal border

Question 11

S3

Answer 11

in early diastole during rapid ventricular filling
increased filling pressure: mitral regurgitation, HF, dilated ventricles (indicates increase in EDV)
normal in children and pregnant women

Question 12

S4

Answer 12

late diastole (atrial kick)
loudest: apex with patient in left lateral decubitus position
high atrial pressure: LVH

Question 13

infective endocarditis

Answer 13

large irregular vegetations on valve cusps (atrial side of AV, ventricular side of semilunar) that can extend to chordae tendon
most mitral valve alone or mitral plus aortic
complications: HF, septic embolism (kidneys, heart, spleen, brain), perforate valve, abscess (check if fever persists after Tx and can perforate septum), fibrosis, calcification
Sx: fever, chills, weakness, dyspnea
signs: murmur, splenomegaly, petechiae
labs: high ESR, anemia, proteinuria
other: osler nodes, subungual splinter hemorrhages, Janeway lesions, Roth spots

Question 14

pathogenesis of infective endocarditis

Answer 14

valvular endothelial injury, platelet and fibrin deposition, microbial seeding, microbial multiplication

Question 15

How do you determine if it is endocarditis?

Answer 15

vegetations: transesophageal echo > transthoracic
Dx: culture (alert lab because some slow growing)

Question 16

most common causes of endocarditis

Answer 16

staph aureus: acute
strep viridans: subacute (weeks)
through dental or central line
other: IV drug abuse, prosthetic valves, lesions of lg. bowel

Question 17

mechanical valves

Answer 17

need lifelong anticoagulation

Question 18

bioprostheses valves

Answer 18

deteriorate: half need replacement in 10 yrs

Question 19

complications of replacement valves

Answer 19

leak, thrombosis, embolism, bleeding, endocarditis

more complications in mechanical valves

Question 20

Libman-Sacks endocarditis

Answer 20

lupus
small-medium vegetations on multiple valves (either/both side)
rarely embolizes

Question 21

Virchow’s triad

Answer 21

thrombosis: endothelial injury, abnormal flow, and hyper coagulability

Question 22

carcinoid syndrome

Answer 22

serotonin released from tumor
Sx: flushing, diarrhea, dermatitis, bronchoconstriction
systemic: can get heart disease of endocardium and valves of right heart
white plaque like thickening

Question 23

rheumatic heart disease

Answer 23

fever phase: small, warty vegetations along the lines of closure of valve leaflets

Question 24

marantic endocarditis

Answer 24

nonbacterial thrombotic endocarditis
small, bland vegetations attached to line closure (can be one or many)
precursor to infective endocarditis

Question 25

acute regurgitation

Answer 25

no hypertrophy
cause: ischemia (post-MI), infection, dissection
mitral: sudden rise in V wave (atrial pressure)
Sx: murmur, pulmonary edema without enlargement

Question 26

How is stenosis assessed?

Answer 26

1. tightness
2. pressure gradient on each side of valve
3. Gorlin: CO and pressure gradient determine severity of stenosis
4. flow

Question 27

How is regurgitation assessed?

Answer 27

visualize

Question 28

indications of surgery in infective endocarditis

Answer 28

1. HF unresponsive to medication
2. uncontrolled infection
3. recurrent major embolization

Question 29

When is endocarditis prophylaxis recommended?

Answer 29

dental procedures, surgery (GI or respiratory mucosa)