Murmurs

Question 1

Standing or Valsalva maneuver

Answer 1

Increases murmurs of MVP or HCM

Question 2

Sustained handgrip

Answer 2

Increases murmur of mitral regurgitation

Question 3

Standing or Valsalva maneuver

Answer 3

Decreases all murmurs except for that of MVP or HCM

Question 4

Sustained handgrip

Answer 4

Decrease murmur of aortic stenosis

Question 5

Diastolic murmurs

Answer 5

Aortic regurgitation, pulmonic regurgitation, mitral stenosis, patent ductus arteriosus

Question 6

Inspiration

Answer 6

Increases right-sided heart murmurs

Question 7

Expiration

Answer 7

Increases left-sided heart murmurs except pulmonary stenosis which disappears with inspiration

Question 8

Aortic stenosis

Answer 8

Generally caused by age-related calcific valve degeneration.

• Congenital bicuspid aortic valves usually calcified and stenosed between 40-70 years of age.
• Normal trileaflet aortic valves can stenotic at >75 years of age

Question 9

Aortic stenosis-symptoms

Answer 9

Heart failure, angina, syncope with exercise

Question 10

Aortic stenosis murmur

Answer 10

• Mid to late peaking diamond-shaped systolic murmur at the right upper sternal border or suprasternal notch radiates to the neck
• S4 gallop
• Often a decreased or absent aortic component of the second heart sound.
• Paradoxical S2 split with severe aortic stenosis.
• Ejection click is classic and comment a bicuspid aortic valve
• 👀Systolic thrill sometimes felt over the upper precordium and suprasternal notch
• Pulses parvus et tardus
• Murmur louder with squatting
• Doppler echocardiogram very accurate in detecting severe aortic stenosis

Question 11

Aortic stenosis-echocardiogram findings

Answer 11

-Doppler echocardiogram very accurate in detecting severe aortic stenosis

Mean valve pressure gradient or maximum valvular velocity:

• Mild <25 mmHg
• Moderate 25-40 mmHg
• Severe >40 mmHg (=l >4 point m/ s)

Area:

• Mild 1.9-1.6 cm²
• Moderate 1.5-1.1 cm²
• Severe = <1 cm²

Question 12

Aortic stenosis prognosis

Answer 12

• Worst prognosis of all valvular lesions
• Severe aortic stenosis with 10% risk of sudden death
• Angina median survival 5 years
• Syncope median survival 3 years
• Heart failure median survival 2 years
• Surgical treatment only option, medical therapy not effective

Question 13

Aortic stenosis valve replacement indication

Answer 13

• Severe aortic stenosis
• Symptomatic aortic stenosis

Transcatheter aortic valve replacement/TAVR recommended for patients with prohibitive risk for surgery for aortic valve replacement and predicted post TAVR survival >12 months.

Question 14

Chronic aortic regurgitation murmur

Answer 14

-👀Murmur is a decrescendo diastolic, high-pitched blowing loudest at the left sternal border if due to the aortic leaflet (third intercostal space, with patient leaning forward and exhaling) and at the right sternal border if due to aortic dilatation. Also low pitched late diastolic rumble (Austin Flint)

Question 15

Chronic aortic regurgitation treatment

Answer 15

• Monitor with echocardiogram, follow LV size and function.
• Medical treatment for severe AR is vasodilators (ACE inhibitor/ARB, diuretics). Not indicated if nonsevere AR.
• Surgical treatment if patient is symptomatic or severe AR or EF <50%

Question 16

Mitral stenosis

Answer 16

• Cause: Almost always due to rheumatic fever, relatively rare in the US. Other causes SLE, rheumatoid arthritis, severe valve calcification.
• Atrial fibrillation is common.
• 👀Hemoptysis can occur due to pulmonary venous hypertension.
• 👀Murmur: Diastolic rumble with diastolic opening snap at apex.
• Treatment percutaneous mitral balloon valvotomy for patients with symptomatic or severe mitral stenosis (mitral valve area = <1.5 cm² or pulmonary hypertension). Surgical mitral valve replacement or repair is less desirable, and alternative for patients who cannot undergo p.m. MD or failed PND. Mitral valve surgery is also considered for moderate stenosis (1.6-2.0 cm²) who are undergoing other cardiac surgery.

Question 17

Chronic mitral regurgitation

Answer 17

• Murmur holosystolic murmur.
• Atrial fibrillation is common.
• S1 is softer absent, S2 is widely split. S3, and is severe mitral regurgitation.
• Treatment medical with diuretics and afterload reducers (ACE inhibitor/ARBs). Surgery indicated if symptomatic (Stage D) or (Stage C) asymptomatic with LVEF <60% and/or LV enlargement with LV end-diastolic diameter greater than = >40 mm, or pulmonary artery pressure >50 mmHg, or new onset atrial fibrillation. Repair preferable to replacement.

Question 18

Mitral valve prolapse

Answer 18

• Most common valvular lesion, more common in women.
• Midsystolic click. If there is also mitral regurgitation, click is followed by a mid to late systolic murmur.
• Treatment reassurance of generally benign course, advised to follow healthy lifestyle. Beta-blocker may help with symptom management.

Question 19

Tricuspid stenosis

Answer 19

• Rare. Causes: Rheumatic fever usually rheumatic fever, congenital, carcinoid syndrome, endocarditis.
• Murmur: Diastolic along left sternal border that increases with inspiration (as with all right-sided heart murmurs).
• Large a venous waves.
• Treat underlying disease. Consider tricuspid valve surgery for patients with stage C or D (symptomatic) disease.

Question 20

Tricuspid regurgitation

Answer 20

• Cause: Usually caused by right ventricular dilatation and/or pulmonary hypertension. Can also be caused by rheumatic heart disease, endocarditis, carcinoid, and Epstein anomaly.
• Endocarditis affecting the tricuspid valve typically in IV drug users, often caused by Staphylococcus, also consider Candida.
• Murmur: Holosystolic along the lower left sternal border that increases with inspiration. Does not radiate to the axilla.
• Large V waves.
• Treat underlying disease. Valve rarely needs to be removed unless endocarditis with Candida or severe destruction of the valve..

Question 21

Pulmonic stenosis

Answer 21

• Cause: Virtually always congenital and typically does not progress. Generally not seen with other abnormalities but does occur in Noonan syndrome in which patient also has low-set ears and hairline.
• Murmur: Ejection click and crescendo-decrescendo systolic murmur changes in intensity with respiration.
• Prominent a venous wave.
• Treatment if needed, percutaneous balloon valvuloplasty

Question 22

Pulmonic regurgitation

Answer 22

• Cause: Typically due to pulmonary hypertension. Pulmonary artery pressure >60 mmHg.
• Murmur: Diastolic, high-pitched, best heard over the second and third intercostal spaces, typically louder during inspiration.

Question 23

Epstein anomaly

Answer 23

• Tricuspid septal leaflet disposition lower in the ventricle, apically displaced, so the right atrium appears huge and the right ventricle small.
• Occasionally seen with atrial septal defect and WPW.
• Tricuspid regurgitation murmur is common. A sound like a flapping sail may be present.