Valvular Heart Disease Flashcards
Describing murmurs?
- Timing
- Location
- Grade
- Character
- Shape
- Pitch
- Radiation
Timing of murmurs?
A murmur is either:
1. systolic
2. diastolic
3. continuous throughout systole and diastole.
- Remember that systole occurs between the S1 and S2 heart sounds, whereas diastole occurs between S2 and S1
The 4 main listening posts on the chest for determing the location of murmurs?
- A = aortic valve post (right upper sternal border)
- P = pulmonic valve post (left upper sternal border)
- T = tricuspid valve post (left lower sternal border 4th ICS)
- M = mitral valve post (apex)
- E = ‘Erb’s point’ (left sternal border 3rd ICS)
Aortic murmurs?
sytolic murmurs
1. aortic stenosis
2. aortic valve sclerosis
3. flow murmur
Pulmonary valve murmur?
systolic murmur
1. flow murmur
2. pulmonic stenosis
Tricuspid valve murmurs?
systolic
1. tricuspid regurgitation
2. ventricular septal defect
diastolic
1. tricuspid stenosis
2. atrial septal defect
Mitral valve murmurs?
systolic
1. mitral regurgitation
diastolic
1. mitral stenosis
Erbs point murmurs?
diastolic
1. aortic regurgitation
2. pulmonic regurgitation
systolic
1. hypertrophic obstructive cardiomyopathy (HOCM)
Where to hear a PDA murmur?
left 1st rib
Grading systolic murmurs?
Grade 1
very faint , may only be heart by expert and not heard in all positions
Grade 2
soft and heard in all positions
Grade 3
moderately loud but no thrill
Grade 4
very loud with associated thrill
Grade 5
loud with the edge of stethoscope tilted against the chest
Grade 6
very loud and can be heard with the stethoscope just off the chest wall
Diastolic murmurs?
Grade 1
Very soft and can only be heard by exert or very quite room
Grade 2
Soft
Grade 3
Moderately loud
Grade 4
Loud or associated with a thrill
Character of the murmur?
Systolic murmurs can be classified as either
1. midsystolic (systolic ejection murmurs, or SEM),
- A midsystolic murmur begins just after the S1 heart sound and terminates just before the P2 heart sound: thus, S1 and S2 will be distinctly audible
2. holosystolic (pansystolic)
- begins with or immediately after the S1 heart sound and extends up to the S2
3. late systolic.
4. Mid-late systolic murmur
- begins significantly after S1 and may or may not extend up to the S2.
Shape of the murmur?
- The shape of a murmur describes the change of intensity throughout the cardiac cycle.
- Murmurs are either crescendo, decrescendo, crescendo-decrescendo or uniform
Pitch of a murmur?
A murmur will be high pitched if there is a large pressure gradient across the pathologic lesion or
- low: if the pressure gradient is low
- high: if the pressure gradient is high
Low pitched murmurs?
murmur of mitral stenosis
- is low pitched because there is a lower pressure gradient between the left atrium and the left ventricle during diastole.
High pitched murmur?
murmur of aortic stenosis
- is high pitched because there is usually a large pressure gradient between the left ventricle and the aorta.
How to listen to pitch of the murmurs?
Remember high-pitched sounds are heard with the diaphragm of the stethoscope, whereas low-pitched sounds are heard with the bell.
Radiation of murmurs?
While murmurs are usually most intense at one specific listening post, they often radiate to other listening posts or areas of the body.
1. murmur of aortic stenosis frequently radiates to the carotid arteries
2. murmur of mitral regurgitation radiates to the left axillary region
Causes of mitral stenosis?
- Acquired is often from rheumatic heart disease
- Congenital causes are very rare
Clinical presentation of mitral stenosis in history?
- SOB
- orthopnea
- PND
- hemoptysis
- abdominal swelling or limb swelling
Clinical presentation of MS in auscultation?
Loud S1
Opening snap
Low pitched late diastolic rumble which gets louder towards end of diastole
Palpable P2
Severe MS associated with softening of S1 or absent opening snap and a soft but long murmur, and a small pulse pressure
Diagnosis and evaluation of MS?
- CXR
- show an enlarged left atria or pulmonary edema or right chamber enlargement, pulmonary hemisiderosis - Cardiac ECHO
- Assess valve morphology and size
- If valve are is less than 1cm then there is critical stenosis
- Assess involvement of other valves
Treatment of MS?
- If asymptomatic
- No specific treatment - If symptomatic
- Percutaneous balloon valvotomy
- If heavily calcified, advice for open surgery with valve replacement - Pregnancy is contraindicated
- Offer C/S very early in pregnancy
Causes of mitral regurgitation?
- Myoxamatous (floppy) valve
- Ruptured chordae tendineae
- Previous endocarditis
- Papillary muscle dysfunction
- Rheumatic disease
- Functional
Clinical presentation of acute MR?
may present with acute pulmonary edema, low cardiac output, and an innocent murmur
Clinical presentation of chronic MR?
- Hyperkinetic LV
- Pansystolic murmur
- Murmur often very loud and radiates to the axilla
- Louder with expiration at the apex
Diagnosis and evaluation of MR?
- CXR
- Cardiomegaly, left atrial enlargement, pulmonary congestion, pulmonary artery enlargement - ECG
- LAE - Cardiac ECHO
- Distinguishes between functional and primary MR
- Looks at valve morphology
- Vegetations and perforations
- Assess LV cavity size and functionality (EF)
Treatment of MR?
- Medical management with diuretics especially with the functional MR
- Surgery is often most beneficial treatment modality for most MR
- MR begets MR - Mitral valve repair preferred over replacement
Causes of aortic stenosis?
- Congenital unicuspidal valve
- Congenital bicuspid valve
- Calcified valve which often develops from age 30 to 40s
- Degenerative calcific valve
Starts with an aortic sclerosis at age 50-60s
Clinical presentation of AS?
- Systolic ejection murmur
- Crescendo-decrescendo murmur
- Pick late in systole if severe - Slow rising carotid pulses
- Parvus et tardus - Classic symptoms
- Angina, SOB, and dizziness or syncope
Diagnosis and evaluation of AS?
- ECG
- LVH but may be normal - Cardiac ECHO
- Shows morphology of the valve
- Calculate gradient and valve area
Treatment of AS?
No proven medical therapy
1. Avoid nitrates as they can dangerously lower venous return
2. Surgery or percutaneous intervention are only proven treatments
Valvular Causes of aortic regurgitation?
- Bicuspid aortic valve
- Previous endocarditis
- RHD
Aortic disease causes of aortic regurgitation?
- Marfan syndrome
- Syphillis
- Aortic dissection
Clinical presentation of AR?
- Abnormal pulses
- Bounding pulses
- Wide pulse pressure
- Early diastolic murmur loudest at 5. Erb’s point and loudest in expiration
Diagnosis and evaluation of AR?
- Lab
- VDRL, TPHA - Cardiac ECHO
- Distinguishes aortic valve vs aortic wall
- Determines valve morphology
- Detects vegetations or perforations
- Assess associated valve lesions
Signs of AR?
Quincke’s sign
capillary pulsation of the nail bed
Corrigan sign
prominent carotid pulsations
Water hammer or collapsing pulse
radial pulse disappears when the arm is lifted perpendicular to the body
De Musset’s sign
head nodding with each heart beat
Hill’s sign
increased blood pressure of more than 20mmHg in the legs compared to the arms
Duroziez’s sign
systolic and diastolic murmurs over the femoral artery on gradual compression of the artery
Traube’s sign
double sound over femoral artery when its compressed distally
Maynes sign
decrease in diastolic blood pressure of more than 15mmHg when arm is held above the head
Rosenbach’s sign
liver pulsation with each heart beat in the absence of severe TR
Austin Flint Murmur
short rumbling diastolic murmur due to the impinging regurgitant jet of blood on the anterior mitral valve leaflet
Becker’s signs
accentuated renal artery pulsations
Gerhards sign
pulsation of the spleen
Landolfi’s signs
alternating vasoconstriction and vasodilatation of the pulpits with each heart beat
Lincoln sign
exaggerated movement of the ankle when one leg is crossed over the other
Treatment of AR?
No proven medical therapy
Surgery and percutaneous intervention only treatment modalities
Primary valve disease causes of tricuspid valve disease?
- Rare
- Mainly congenital
Acquired tricuspid valve disease?
- Left heart disease
- Pulmonary hypertension
- Endocarditis
- Pacemaker lead injury
- Radiation
- Trauma
Clinical presentation of tricuspid valve disease?
Signs of right heart disease
1. Peripheral edema
2. ascites
3. hepatomegally
4. raised JVP
5. right ventricular heave
6. right sided S3
Treatment of tricuspid valve disease?
Asymptomatic
1. Usually associated with mild to moderate TR
2. No treatment needed
Symptomatic
1. Associated with severe TR
2. Treat medically with diuretics
3. Can consider TV repair or replacement
Causes of pulmonary valve stenosis?
Pulmonary valve stenosis are rare and often associated with other congenital abnormalities
Causes of pulmonary regurgitation?
- Often previous pulmonary valve surgery
- Pulmonary hypertension of any cause
- Previous endocarditis
Treatment of pulmonary regurgitation?
Consider surgery if
Symptoms related to PR like arrhythmias
RV systolic EF less than 40%
Progressive RV dilatation
Poor exercise tolerance
Severe PR in a patient who is undergoing other cardiac surgery
Purpose of antibiotic prophylaxis?
Goal is to prevent Infective endocarditis
Indications for prophylactive antibiotics?
- Prosthetic valves(including bioprosthetics), or valve repair with additional prosthetic material
- History of infective endocarditis
- Congenital cyanotic heart disease
- Unrepaired, or incompletely repaired or repaired with prosthetic material
- Any valve disease in a transplanted heart
What procedures require prophylaxis?
- Dental procedures that involve manipulation of the gingival tissue or periapical tooth region or mucosal perforation
- Respiratory tract procedures that involve incision or biopsy
- Procedures in patients with GIT or urinary tract infections
- Procedures on infected skin
Prophylactic treatment for most dental or respiratory procedures?
Amoxicillin 2 gm iv given 30-60min before procedure
Alternative prophylactic treatment for penicillin allergic patients?
- Cephalexin 500mg iv stat
- azithromycin 500mg iv stat
- clarithromycin 500mg iv stat or
- Clindamycin 900mg iv stat
