Murmurs and valvular heart disease
Dr. John Edmond MD FRCP
Objectives
• By the end of this session, you will be able to;– Describe the symptoms and clinical findings
of the most common valvular abnormalities– Discuss the clinical importance of identifying
cardiac murmurs– Understand the limitations of auscultation
What is a murmur?
Abnormal heart sounds that are produced as a result of turbulent blood flow which is sufficient to produce audible noise.
Are murmurs important?
Of course!But only if taken into account as part of the
clinical examination of the patient
Clinical vs. noiseVentricular septal defect;
Small hole;
High pressure maintainedbetween LV and RV throughout systole.
High velocity flow, all through systole.
Big noise, all through systole
Clinical vs. noiseVentricular septal defect;
Big hole;
Pressure quickly equalises between LV and RV.
High volume flow, but no great velocity and only at beginning of systole.
Little noise, early systoleonly
How the system works
• The heart is a pump.– Passive flow
• Gravity• Pressure from muscle pumps
– Active flow• Atrial and ventricular contractions
– Both require valves to ensure flow is in correct direction.
• The system works in series;
– Venous return– Right atrium– Right ventricle– Pulmonary artery– Pulmonary veins– Left atrium– Left ventricle– Aorta
Tricuspid valve
Pulmonary valve
Mitral valve
Aortic valve
Basic valvular anatomy
Small groups, 15 minutes
• Aortic stenosis• Aortic regurgitation• Mitral stenosis• Mitral regurgitation
Describe;
– Haemodynamics– Symptoms– Clinical signs
Aortic stenosis
Aortic stenosis
Aortic stenosis
• Haemodynamics
– Left ventricle hypertrophies– Massively increased LV pressures– High LV filling pressure increases LA
pressure– Low systemic blood pressure
Aortic Stenosis
NB: Pullback gradient is different to PIG obtained by echo
Aortic Stenosis
Aortic stenosis
• Haemodynamics– Massively increased LV pressures– Low systemic pressure
• Symptoms– Breathlessness– Angina– (Pre) syncope– Sudden cardiac death
Aortic stenosis
• Signs– Low pulse pressure – Slow rising pulse– Heaving apex– Murmur, radiating to neck– Quiet A2
Aortic stenosis
• Timing Systolic
• Shape Crescendo-decres’
• Location Upper right sternal border
• Radiation To carotids
• Intensity Variable
• Pitch High
• Quality Harsh
Aortic regurgitation
Aortic regurgitation
Aortic regurgitation
• Haemodynamics– Left ventricle dilates– Increased diastolic pressure leads to
increased atrial pressures.
• Clinical– Breathlessness– Angina
Aortic regurgitation
• Haemodynamics– Left ventricle dilates– Increased diastolic pressure leads to
increased atrial pressures.
• Clinical– Breathlessness– Angina
Aortic regurgitation
• Signs– Quinkes sign– Corrigans sign– De Musset’s sign– Duroziez’s sign– Large volume, collapsing pulse– Apex displaced, thrusting– Murmur(s)
Aortic regurgitation
• Timing Early….diastole
• Shape Decrescendo
• Location Aortic
• Radiation Lower L sternal edge
• Intensity Varied
• Pitch High
• Quality Blowing
Mitral stenosis
Mitral stenosis
Mitral stenosis
• Haemodynamics– Increased left atrial pressure– Increased back pressure into lungs, R heart
• Clinical– Atrial arrhythmias, potentially emboli– Fatigue– Breathlessness– Central cyanosis with “Mitral facies”
Mitral stenosis
Mitral Stenosis
Mitral stenosis
• Haemodynamics– Increased left atrial pressure– Increased back pressure into lungs, R heart
• Clinical– Atrial arrhythmias, potentially emboli– Fatigue– Breathlessness– Central cyanosis with “Mitral facies”
Mitral stenosis
• Signs– Mitral facies– Low volume pulse, often irregular (AF)– Apex not displaced (possibly tapping)– Left parasternal heave– Murmur
Mitral stenosis
• Timing Early-mid diastole (OS)
• Shape Decrescendo
• Location Apex
• Radiation Axilla
• Intensity Varied
• Pitch Low
• Quality Rumbling
Mitral regurgitation
Mitral regurgitation
Mitral regurgitation
• Haemodynamics– Left ventricle dilates– Left atrium dilates– Increased pressure in lungs and R heart
Mitral regurgitation
• Haemodynamics– Left ventricle dilates– Left atrium dilates– Increased pressure in lungs and R heart
• Clinical– Atrial arrhythmias– Breathlessness– May be asymptomatic for many years
Mitral regurgitation
• Signs– Normal pulse (?irregular)– Thrusting displaced apex– Left parasternal heave– Murmur
Mitral regurgitation
• Timing Holosystolic
• Shape Pansystolic
• Location Apex
• Radiation To axilla
• Intensity Variable
• Pitch High pitched
• Quality Blowing
Ventricular septal defect
• Timing Throughout systole
• Shape Pansystolic
• Location Lower L sternal edge
• Radiation Often widely
• Intensity Varied
• Pitch Varied
• Quality Harsh
WHAT IS THE MOST IMPORTANT QUESTION IN
MEDICINE???
WHAT IS THE MOST IMPORTANT QUESTION IN
MEDICINE???
WHY?
Always ask “WHY?”
• Rheumatic fever
• Infection (endocarditis)
• Ischaemic heart disease (acute/chronic)
• LV dilatation (but again, why?)
• Aortic dissection
• Aging (degenerative)
• Congenital
Rheumatic fever
• Streptococcal infection, usually as child
• Generalised febrile illness, sore throat
• Joint disease
• Heart disease
“Rheumatic fever licks the joints but bites the heart”
Rheumatic fever
• Generally a disease of poverty
• Extremely rare in the UK
• Endemic in 3rd World
• Important part of any introductory history.
What happens if something goes wrong
• Nothing!– Compensation over many years– Haemodynamics slowly worsen– Patient feels “old”
• Breathless• Tired all the time• Chest pain
– Final decompensation…..
• Acute mitral regurgitation
• Acute ventricular septal defect
• Infective endocarditis leading to valve destruction
Acute valvular changes are much less well tolerated than chronic disease, leading to acute heart failure, often fatal.
Things can develop acutely
What can be done?
• Early assessment of patient– Clinical history– Clinical examination– ECG– Chest xray– Echocardiography– Cardiac catheterisation
• Regular assessment of patient
Echocardiography
• Ultrasound examination of the heart and great vessels
• Can be transthoracic (TTE) or transoesphageal (TOE)
Echocardiography pitfalls
• Ultrasound waves used;– Limited discrimination– Have to pass through fat, past lungs etc– Takes time to get good images.
• Transoesphageal echo can help.
What can be done?
• Medical therapy– Diuretics– Vasodilators– Anti-arrhythmics– Aspirin or anticoagulation
• Surgery– Percutaneous– Open surgery
Valve surgery
• Alter the native valve– Valvotomy– Open repair
• Replace the valve– Homograft– Xenograft– Metalic valve
Xenograft
• Do not require anticoagulation
• Can degenerate
Metallic valve
• Do require anticoagulation;– INR often >3.0
• Apparently last for ever!
• Audible valve clicks
Infective endocarditis
Infection on a heart structure– Usually an already abnormal valve– Can be any other structure or abnormality
– Usually bacterial– Can be fungal
Overall mortality 20%
Infective endocarditis
Presents as generalised sepsis– Fevers, night sweats, weight loss– New murmur– Raised inflammatory markers– Positive blood cultures
“Duke Criteria” for diagnosis.A) +ve blood cultures, endocardial involvementB) Predisposition, fever, vascular phenom’,
serological tests, etc.
Infective endocarditis
• Commonly;– Prosthetic valve– Prior endocarditis– Aortic valve disease– Mitral valve disease– Coarctation– Congenital heart
disease– Tricuspid valve in drug
addicts
• Uncommon;– HCM– Pacing wires– ASD– Coronary stents– Surgically repaired
VSD or ASD with no residual defect
Duke criteria
• MAJOR CRITERIA– +ve blood culture for typical organism– Evidence of endocardial involvement
• MINOR CRITERIA– Predisposition– Fever– Vascular phenomena– Immunological phenomena– Microbiological evidence– Echocardiographic evidence
Diagnosis;
2 major1 major + 3 minor5 minor
Questions??
Valvular heart disease;summary
• Valvular heart disease is a common cause of cardio-respiratory symptoms
• Ausculatation alone dose not help diagnose or classify the disease
• As always in medicine;– Put THE WHOLE picture together– Ask yourself why this is happening to your
patient