Murmurs and valvular heart disease Dr. John Edmond MD FRCP.

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