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  Diastolic decrescendo murmur
sternal border; prominent during heard best at 3rd ICS along the
presystole in sinus rhythm; left sternal border
augmented in inspiration; reduced  If soft – best heard by diaphragm
during expiration and valsalva leaning forward
maneuver  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  LV heaves displaced laterally and
THRILLS lateral 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
HEART apex; Loud S1 arteries
SOUNDS  S2 closely split  Duroziez’ s sign at femoral art. –
 Loud P2 (parasternal lift) to-and-fro murmur
 Absent A2
 (+) S3; occasional S4
CHAR.  LAE/ AF (thrombi arise particularly  RAE – tall p waves lead II and V1  Marked aortic dilatation; aortic
FEATURES at the LA appendage). root disease;
 RVH  Assoc. with Marfan syndrome,
 RAE – RV tap at L sternal border VSD, 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
 Hemoptysis  Pulmonary congestion initially dissection, trauma, LV cannot
 Systemic embolization  Fatigue and discomfort; little dilate to maintain SV; Pulmo
 Hoarseness dyspnea edema and cardio shock may
 Chest pain  R sided HF deveop rapidly
 Palpitation  If severe = hepatic congestion,  CHRONIC SEVERE AR
 Malar flush with pinched blue facies cirrhosis, jaundice, malnutrition, - Asymptomatic for 10-15 yrs,
anasarca, ascites 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 2D: TV is thick and domes in diatole
valve orifice
book  LV symptoms but without LV  Rheumatic in origin; more common to  Rheumatic in origin; may result
dysfunction; females; from infective endocarditis
 Caused by RF;  Augmented diastolic pressure
 Elevated LAV pressure gradient gradient bet. 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
 Grade III/VI, holosystolic sternal border the base after S1
 Radiates to axilla  Inc. with inspiration and dec. with  Low pitched rough rasping
 +isometric exercise valsava and expiration loudest at the base of the heart in
 - Valsava (CARVALLO’s sign) the 2nd ICS radiating to carotid
 Acute MR is decrescendo arteries (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
THRILLS  Systolic thrill at apex heart
 Palpable S3  LV impulse displaced laterally
 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
SOUNDS  Low pitched S3 LV hypertrophy
 S4 often audible
 Sea gull quality in ruptured tendinae
CHAR.  LVH, LAE, RAR, RVE  Prominent v wave and rapid y  Carotid upstroke delayed,
FEATURES  Associated with MVP and HOCM descent peripheral pulses rises slowly to a
 LV afterload reduced  Prominent c-v wave delayed sustained peak (PULSUS
 EF rises in severe MR  RV enlargement, inf. Wall infarcts PARVUS et TENDUS)
 Atrial pulse show sharp upstroke  RA enlargement  Double apical impulse
 Reversible if pulmonary HPN is  Obstruction of LV outflow
relieved
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  syncope
reflux  CHF – L sided in severe AS
 Systemic venous congestion
 Reduction of CO
Dx  TTE and Doppler imaging  Color flow Doppler echo  Doppler – focal thickening or
 LV EDV-ESV, and EF calcif of 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  Functional TR and secondary to  Males, chronic valvular heart
 of mitral valve dilatation of tricuspid annulus  Due to degenerative calcification
 Papillary muscle rupture, chordae  Associated with Ebstein of aortic cusps
tendinae muscle group malformation  Age-degenerative calcific AS or
 Caused by RHD senile or sclerocalcific AS – most
 Males commonly common cause
 may occur as atrioventricular  Atherosclerosis and vascular
cushion 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  ACE, bblocker, nitrolgycerine,
 Cardioversion required statins
 ACE, Bblockers, diuretics, digitalis  Tricuspid annuloplasty, tricuspid  Operations
 Valvuloplasty, annuloplasty ring valve replacement  Aortic root reconstruction,
 In AF- left atrial Maze procedure or coronary bypass,
radiofrequency ablation  Percutaneous balloon aortic
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  Squatting
systolic crescendo-decrescendo  isometrics
murmur
 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  Murmur appearing after birth  Thrill and continuous MACHINERY
at the 4th ICS and along L sternal border  Holosystolic murmur on the L sternal murmur (below L clavicle –
border radiating rightward hallmark)
 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  2D echo - LVE 
deviation 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 MURMUR  Murmur of pulmonic stenosis
space  Absent P2
 Additional systolic and continuous murmurs
over the lateral thoracic wall
THRILL  THRILL 
OTHERS  OTHERS 
HEART HEART
SOUNDS SOUNDS
CHAR.  Narrowing of the lumen of the aorta distal to CHAR.  Most common cyanotic heart disease in adults
FEATURES the origin of L subclavian artery near FEATURES  History of exercise intolerance and squatting
ligamentum arteriosum  Pulmonary stenosis overriding the aorta
 Bicuspid aortic valve
 Circle of Willis aneurysms

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

claudication 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  Malaligned VSD,
TURNER’S syndrome  Obstruction to RV outflow,
 Enlarged pulsatile collateral vessels may be  Aortic override of VSD and
palpated in 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  Stenting of branch pulmonary stenosis
dilatation

Zetmontemayor 09’11