VALVULAR HEART DISEASES (Diastolic Murmurs) – CODE: DARTS; S2 – diastolic murmur – S1

MS – MITRAL STENOSIS TS – TRICUSPID STENOSIS AR – AORTIC REGURGITATION

MURMUR  Diastolic rumbling at apex  Diastolic murmur at left lower sternal  Diastolic decrescendo murmur
border; prominent during presystole in heard best at 3rd ICS along the left
sinus rhythm; augmented in inspiration; sternal border
reduced during expiration and valsalva  If soft – best heard by diaphragm
maneuver leaning forward
 High pitched, blowing radiating to
axilla (CODE: ARA)
 Austin flint murmur- soft low
pitched rumbling mid-diastolic
murmur
HEAVES/  Diastolic thrill at apex; px in left lateral  LV heaves displaced laterally and
THRILLS recumbent position inferiorly
 Diastolic thrill at L sternal border
 Systolic thrill at suprasternal notch
 Carotid atrial pulse is bisferiens
OTHERS  Opening snap heard at expiration at  Traube’s sign over femoral arteries
HEART apex; Loud S1  Duroziez’ s sign at femoral art. – to-
SOUNDS  S2 closely split and-fro murmur
 Loud P2 (parasternal lift)  Absent A2
 (+) S3; occasional S4
CHAR.  LAE/ AF (thrombi arise particularly at the  RAE – tall p waves lead II and V1  Marked aortic dilatation; aortic root
FEATURES LA appendage). disease;
 RVH  Assoc. with Marfan syndrome, VSD,
 RAE – RV tap at L sternal border ankylosing spondylitis
 Fish-mouth valve  Widened aortic annulus and separated
aortic leaflets
 LV entire SV is ejected into aorta
 Inc. preload or EDV is the major
hemodynamic compensation for AR
 Jarring of body and bobbing of head
with each systole
 Uncomfortable awareness of
heartbeat

MS – MITRAL STENOSIS TS – TRICUSPID STENOSIS AR – AORTIC REGURGITATION

CLINICAL  L sided HF  Systemic venous congestion,  ACUTE SEVERE AR
SYMPTOMS  R sided HF hepatomegaly, ascites, edema - Infective endocarditis, aortic
dissection, trauma, LV cannot
  Hemoptysis  Pulmonary congestion initially dilate to maintain SV; Pulmo
 Systemic embolization  Fatigue and discomfort; little dyspnea edema and cardio shock may
 Hoarseness  R sided HF deveop rapidly
 Chest pain  If severe = hepatic congestion, cirrhosis,  CHRONIC SEVERE AR
 Palpitation jaundice, malnutrition, anasarca, ascites - Asymptomatic for 10-15 yrs,
 Malar flush with pinched blue facies uncomfortable awareness of
heartbeat, sinus tachycardia, PVC,
- Dyspnea – first symptom of dec.
cardiac reserve
- Orthopnea, PND, diaphoresis,
chest pain
- Congestive hepatomegaly, ankle
edema - late
Assoc. lesions  Carvallo’s sign (pansystolic murmur  Annulo-aortic ectasia
together with TR)  Osteogenesis imperfect
 Graham Steell murmur of PR  Severe HPN
 Syphilis and a. spondylitis
 Myocardial ischemia
 Corrigan’s pulse – water hammer
pulse
 Quincke’ s pulse
Dx 2D echo: thick MV leaflets, reduced valve 2D: TV is thick and domes in diatole

orifice
book  LV symptoms but without LV  Rheumatic in origin; more common to  Rheumatic in origin; may result from
dysfunction; females; infective endocarditis
 Caused by RF;  Augmented diastolic pressure gradient bet.
 Elevated LAV pressure gradient RA and RV
– hallmark of MS  Tall a wave and prolonged y descent
 Inc. HR shortens diastole
= tachycardia + AF +inc LA pressure
= pulmo edema and hemoptysis
 Inc. LA and PA wedge pressure
= atrial contraction (a wave) and
gradual pressure decline (y descent)
VALVULAR HEART DISEASES (Systolic Murmurs) – CODE: SAPS; S1 – systolic murmur – S2
MR- Mitral Regurgitation TR- Tricuspid Regurgitation AS- Aortic Stenosis
MURMUR  Apical systolic murmur  Blowing Holosystolic murmur at L  Mid-systolic ejection murmur at the
 Grade III/VI, holosystolic sternal border base after S1
 Radiates to axilla  Inc. with inspiration and dec. with  Low pitched rough rasping loudest
 +isometric exercise valsava and expiration (CARVALLO’s at the base of the heart in the 2nd
 - Valsava sign) ICS radiating to carotid arteries
  Acute MR is decrescendo (CODE: CAS)
 Chronic MR plateau  Sometimes at the apex or
GALLAVARDIN EFFECT
 Grade III/VI
HEAVES/  LV heave  RV pulsations at L parasternal  systolic thrill at the base of the heart
THRILLS  Systolic thrill at apex  LV impulse displaced laterally
 Palpable S3 
 Displaced apex beat laterally (chronic) in
acute not displaced
OTHERS  Soft S1 or absent   Paradoxic splitting of S2
HEART  Wide splitting of S2  S4 is audible at the apex reflects LV
SOUNDS  Low pitched S3 hypertrophy
 S4 often audible
 Sea gull quality in ruptured tendinae
CHAR.  LVH, LAE, RAR, RVE  Prominent v wave and rapid y descent  Carotid upstroke delayed,
FEATURES  Associated with MVP and HOCM  Prominent c-v wave peripheral pulses rises slowly to a
 LV afterload reduced  RV enlargement, inf. Wall infarcts delayed sustained peak (PULSUS
 EF rises in severe MR  RA enlargement PARVUS et TENDUS)
 Atrial pulse show sharp upstroke  Reversible if pulmonary HPN is relieved  Double apical impulse
 Obstruction of LV outflow
SYMPTOMS  Dyspnea, orthopnea  Edema, ascites, Jaundice, neck vein  3 cardinal symptoms:
 Pulmonary edema distention (R sided)  Angina pectoris
 Palpitation – start of AF  Hepatomegaly, pleural eff, systolic  Exertional dyspnea
 R sided HF pulsations of liver, hepatojugular reflux  syncope
 Systemic venous congestion  CHF – L sided in severe AS
 Reduction of CO
Dx  TTE and Doppler imaging  Color flow Doppler echo  Doppler – focal thickening or calcif of
 LV EDV-ESV, and EF valve cusps
 XRAY- calcification, kerley B lines  LVH, ST segment depression and T
wave inversion or LV strain
book  Involve 1 or 5 functional components of  Functional TR and secondary to  Males, chronic valvular heart
mitral valve dilatation of tricuspid annulus  Due to degenerative calcification of
 Papillary muscle rupture, chordae  Associated with Ebstein malformation aortic cusps
tendinae muscle group  Age-degenerative calcific AS or
 Caused by RHD senile or sclerocalcific AS – most
 Males commonly common cause
 may occur as atrioventricular cushion  Atherosclerosis and vascular
defects inflammation
 rapid y descent  Bicuspid aortic valve (BAV)
 regurgitant vol.= more 6oml/beat 
  v wave prominent in LA pressure if acute
MR, if chronic vice versa


Treatment  Warfarin once AF  Isolated TR – operation not required  ACE, bblocker, nitrolgycerine, statins
 Cardioversion  Tricuspid annuloplasty, tricuspid valve  Operations
 ACE, Bblockers, diuretics, digitalis replacement  Aortic root reconstruction, coronary
 Valvuloplasty, annuloplasty ring bypass,
 In AF- left atrial Maze procedure or  Percutaneous balloon aortic
radiofrequency ablation valvuloplasty

MVP – Mitral valve Prolapse

MURMUR  Systolic click murmur syndrome,  Earlier click (dec. LV vol.)
Barlow’s syndrome, floppy valve  Standing
syndrome, billowing mitral leaflet  Valsava
syndrome  Amyl nitrate inhalation
 Mid or late systolic click  Delayed click (inc LV vol.)
 Followed by high pitched, late systolic  Squatting
crescendo-decrescendo murmur  isometrics
 Whooping or honking best heard at the
apex
 DYNAMIC AUSCULTATION
HEAVES/ 
THRILLS
OTHERS 
HEART
SOUNDS
CHAR. 
Excessive mitral leaflet tissue
FEATURES 
Myxomatous degeneration

Inc. acid mucopolysaccharide

Associated with Marfan syndrome,
osteogenesis imperfect, Ehler-Danlos
sysndrome, thoracic skeletal deformities,
straight back syndrome
SYMPTOMS  PVC’s, Vtach, paroxysmal
supraventricular
 Palpitations, light-headedness and
syncope
 Transient cerebral ischemic attacks
Dx  ECG – inverted T waves leads II, III aVF
 Doppler, TTE
book  Genetically determined collagen
disorder
 Dec. collagen type 3
 Females age 15-30; often benign
 Also males of 50 yo
Treatment  Infective endocarditis prophylaxis
 Bblockers, aspirin, warfarin
 Mitral valve repa
CONGENITAL HEART DISEASES – L-to-R SHUNT - acyanotic
ASD – Atrial Septal Defect VSD – Ventricular Septal Defect PDA – Patent Ductus Arteriosus
MURMUR  Mid-diastolic rumbling murmur loudest at  Murmur appearing after birth  Thrill and continuous MACHINERY
the 4th ICS and along L sternal border  Holosystolic murmur on the L sternal murmur (below L clavicle – hallmark)
border radiating rightward  Late systolic accentuation at the L
sternal edge
THRILL  Apical thrill and holosystolic murmur in  Systolic thrill at the L sternal border 
ostium primum defects
OTHERS  Split or normal S1  Loud P2  Bounding pulses and widened pulse
HEART  Accentuated tricuspid valve closure  + S3 pressure
SOUNDS  Widely split S2 fixed in respiration
CHAR.  Diastolic overloading of RV and inc.  Not a R sided murmur  EISENMENGER Syndrome
FEATURES pulmo BF  + CARVALLO’S SIGN  DIFFERENTIAL CYANOSIS – toes
  Prominent RV impulse and palpable  LVE, LAE become cyanotic and clubbed
pulmonary artery pulsation  Cannot appreciate RA because it is  LVH
 LUTENBACHER SYNDROME = ASD posteriorly located
+ MS
SYMPTOMS  AF, respi inf., cardio symptoms, PAH,   Pulmo HPN, R-L shunting cyanosis
bidirectional then R-L shunting of blood will eventually develop
then HF  HF, infective endocarditis – leading
cause of death
Dx  ECG ostium secundum – R axis deviation  2D echo - LVE 
and an rSr’ pattern;
 1st degree HB in sinus venous type
 Ostium primum – L axis deviation
 ECHO- RV and RA dilatation
book  Common in females  
 Sinus Venosus – high in atrial septum
near SVC into RA; assoc. with anomalous
pulmo venous connection from R lung to
SVC or RA
 Ostium Primum – adjacent to AV valves
deformed or regurgitant; common in
Down’s syndrome
 Ostium Secundum – involves fossa ovalis
and midseptal location; probe patency, a
true deficiency of the atrial septum and
implies functional and anatomic patency
Treatment  Repair with patch of pericardium or   Surgical ligation or dividision
prosthetic material, or percutaneous  Coils, buttons, plugs, umbrellas
transcatheter device closure
 Tx of respi symptoms, AF, HF
CONGENITAL HEART DISEASES – COMPLEX CONGENITAL HEART LESION -
ACYANOTIC WITHOUT A SHUNT TETRALOGY OF FALLOT
COARTATION OF THE AORTA TETRALOGY OF FALLOT
MURMUR  Mid-systolic murmur over the L interscapular space MURMUR  Murmur of pulmonic stenosis
 Additional systolic and continuous murmurs over the  Absent P2
lateral thoracic wall
THRILL  THRILL 
OTHERS  OTHERS 
HEART HEART
SOUNDS SOUNDS
CHAR.  Narrowing of the lumen of the aorta distal to the CHAR.  Most common cyanotic heart disease in adults
FEATURES origin of L subclavian artery near ligamentum FEATURES  History of exercise intolerance and squatting
arteriosum  Pulmonary stenosis overriding the aorta
 Bicuspid aortic valve
 Circle of Willis aneurysms

SYMPTOMS  Headache, epistaxis, cold extremities, claudication SYMPTOMS  Severe cyanosis

 with exercise  Severe erythrocytosis
 Systemic hypoxemia
Dx  LVH Dx  ECG – RV hypertrophy
 Dilated subclavian artery  X-ray – BOOT-SHAPED HEART or COEUR EN
 3 sign SABOT
 Notching of the 3rd and 9th ribs 
book  More in males book  FOUR COMPONENTS OF TOF
 More in px with gonadal dysgenesis or TURNER’S  Malaligned VSD,
syndrome  Obstruction to RV outflow,
 Enlarged pulsatile collateral vessels may be palpated in  Aortic override of VSD and
the ICS, axialle  RV hypertrophy due to RV “seeing” aortic pressure
via the large VSD
 Pulmonary blood flow is reduced markedly

Treatment  Surgical Treatment  Angioplasty

 Percutaneous catheter ballon with stent dilatation  Stenting of branch pulmonary stenosis

Zetmontemayor 09’11