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Showing posts with label Valvular heart disease. Show all posts
Showing posts with label Valvular heart disease. Show all posts

Valvular heart disease clinical presentation

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Mitral stenosis clinical presentation

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Aortic stenosis clinical presentation

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What are the investigation findings in aortic stenosis?

Important investigations in aortic stenosis are
  • ECG
  • CXR
  • Echo
  • Cardiac catheterisation
ECG findings in AS
  • Left ventricular hypertrophy with or without strain may be present (LVH + strain). But absence  of LVH does not rule out the presence of critical AS. There is no correlation between LVH voltage criteria and severity of AS.AS severity correlate with total QRS voltage.
  • Pseudo infarction pattern can be seen, which is seen as loss of r wave in precordial leads
  • Left atrial overload can occur.
  • AV block or left anterior hemiblock.
  • Ventricular arrhythmia and  complete heard block if calcification of valve extend into conducting system.
Chest X-ray findings in AS
  • Normal sized heart with post stenotic diltation can occur. If there is cardiomegaly look for cardiac failure or aortic regurgitation.
  • Left atrial enlargement (LAE) – indicate co-existing mitral stenosis (MS).
  • Calcification of aortic valve may be seen.
Echocardiographic findings in AS
  • Stenotic valve
  • Left ventricular hypertrophy
  • Pressure gradient assessment
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Mention the effect of other valvular disease in aortic stenosis (AS) effect of mitral stenosis (MS) on AS

Mention the effect of miral stenosis (MS) on AS
  1. There is decreased severity of angina and syncope due to AS.
  2. Increased chance of atrial fibrillation
  3. Increased chance of pulmonary artery hypertension.
  4. Mitral stenosis decrease the length and intensity of ejection systolic murmur.
Mention the effect of miral regurgitation (MR) on AS
  1. There is decreased severity of angina and syncope due to AS.
  2. Increased chance of atrial fibrillation
  3. Increased chance of pulmonary artery hypertension.
  4. Mitral stenosis decrease the length and intensity of ejection systolic murmur.
What is the effect of AR (Aortic regurgitation) on AS
  1. Pulse volume may be normal if AR is present with AS
  2. Pulse pressure may be normal.
  3. Apex beat is of normal character.
  4. There is an increase in length and intensity of murmur.
What are the auscultatory findings in correlation with age
  1. Split of S2 is usually normal in young.
  2. S2 is usually single in elderly
  3. Aortic ejection click (AEC) is found only  1/3  of people above 50 years.
  4. Loudness of murmur is not well correlated with the severity in adults.
What is silent AS
  1. AS in cardiac failure murmur reappear after treatment of cardiac failure.
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Mitral regurgitation clinical presentation

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Aortic regurgitation clinical presentation

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Medical and surgical management of mitral regurgitation

Management include medical and surgical modalities
Medical management include
  • Prophylaxis of IEC and RF.
  • Afterload reduction is achieved with ACE inhibitors or nifedipin
Symptomatic patient are given
  • Diurectics and digoxin in heart failure
  • In patients with atrial fibrillation
  • Drugs to reduce the heart rate is given.
  • Anti coagulation and cardioversion is given if required
  • Anticoagulants are given in patients with atrial fibrillation and embolic episodes.
Surgical options include 
Mitral valvuloplasty 
MitralValve replacement
Indications for MV repair (Valvuloplasty or annuloplasty) are the following
1.Mitral valve prolapse
2.Mitral valve annular calcification
3.Chordal rupture
4.Papillary muscle rupture
MV repair helps to maintain the annulo cardo papillary muscle continuity.
What are the indication for mitral valve replacement
Class III, IV symptoms
Severe  MR with following
1.Left ventricular ejection fraction <60
2.LV and systolic diameter >50mm by echo.


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Clinical features of papillary muscle dysfunction

Conditions where you get murmur of Papillary muscle dysfunction 
  • Ischemia
  • Dilatation of left ventricle
  • Rupture of papillary muscle
  • Fibrosis of papillary muscle
What are the signs of papillary muscle dysfunction ?
  • Left ventricular S4
  • Late systolic or pansystolic murmur with late systolic accentuation
  • What are the murmurs in papillary muscle dysfunction ?
  • Late systolic murmur
  • Holosystolic with late systolic accentuation (severe LV dusfunction)
  • Holosystolic murmur
  • Decrescendo murmur
What are the characteristic of murmur in papillay muscle dysfunction ?
It is a late systolic murmur, or PSM with late systolic accentuation
Soft murmur of 2/6 intensity
There is poor correlation between intensity and severity of murmur.
Variabilities are present in intensity, configuration of frequency.
What is the basis of murmur in papillary muscle dysfunction ? 
Papillary muscle function is especially needed in the later part of systolic. So the murmur is PSM  with late systolic accentuation.
What is the basis of decrescendo murmur in papillary muscle dysfunction ?
Decrescendo nature of murmur is due to decreased size of left ventricular toward the end of systolic which help in better co-aptation and less reflux. 
What is the significance of S4 in MR due to papillary muscle dysfunction?
Absence of S4 with a late systolic murmur rules out the papillary muscle dysfunction.

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Causes and clinical features of Acute Mitral regurgitation

What are the causes of acute mitral regurgitation
  • Infective endocarditis
  • Acute rheumatic fever
  • Mitral valve prolapse
  • Marfan syndrome
  • Myocardial ischemia
  • Trauma
  • Idiopathic
  • Prosthetic valve dysfunction
What is the clinical presentation of acute MR ?
Acute pulmonary oedema
Hypotension
What are the clinical signs of acute MR ?
Acute mitral regurgitation produces a set of clinical sign different from chronic mitral regurgitation
  • Tachycardia 
  • Hypotension
  • A wave / v wave in JVP
  • Absence of cardiomegaly
  • Forcible apex
  • Palpable P2
  • Thrill present
  • Left parasternal heave present
  • Loud P2
  • LV S3, S4
  • Loud descrendo murmur at the apex

So the striking differences are in blood pressure, absence of cardiomegaly, pulmonary artery, hypertension(PAH), left ventricular S4 (LVS4) and decrescendo murmur 
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Murmur of mitral regurgitation

Type of systolic murmur in MR is determined by the chronicity of murmur and its etiology
  • Holosystolic murmur – Mitral regurgitation begins during isovolumetric contraction phase and continue till isovolumetric relaxation phase. Heard in rheumatic mitral regurgitation
  • Tapering holosystolic murmur occur due to severe mitral regurgitation with a small left atrium occur in acute MR.
  • Holosystolic murmur with mid systolic accentuation is heard in severe mitral regurgitation
  • Holosystolic murmur with late systolic accentuation occur in MVP and papillary muscle dysfunction
  • Late systolic murmur heard in mitral valve prolapse and papillary muscle dysfunction.
Describe the frequency of murmur in MR
Murmur in MR is a high pitched murmur. In severe MR, When the  pressure gradient decreases towards the end of systole low pitched vibrations can occur.
Where will you auscultate for MR murmur?
Classically heard in mitral area
If the anterior leaflet is affected murmur conduct towards axilla
If the posterior mitral leaflet is affected it will be conducted to base of heart.
Murmur may be heard over entire vertebral column if there is large left atrium.
Which is the ideal position, for auscultation  for MR and Why?
Left lateral position is the most suitable position because there is accentuation of halosystolic nature of murmur
Intensity of murmur is increases in this position
What is effect of VPC (Ventricular premature contraction)
Following ventricular premature beat there won’t be any beat to beat variation of murmur.
Following VPV beat to beat variation of murmur occur in aortic stenosis.
What are the causes of decreased intensity of murmur in MR
Murmur may be of decreased intensity in low flow states and associated valve lesion.
Low flow states are Left ventricular dysfunction and Pulmonary artery hypertension
Associated valve lesions that reduce the murmur intensity is Mitral stenosis
Etiology of MR – MR due to following reasons are associated with low intensity of murmur
  • MR due to acute myocardial infarction
  • MR due to left ventricular dilation 
  • MR due to papillary muscle dysfunction
Other causes are 
Obesity
COPD (Chronic obstructive pulmonary disease)
What is Seagull’s murmur
When patient develop infective endocarditis over mitral regurgitation it will alter the character of murmur resulting in musical quality to the murmur. Ruptured chordac act as the string of musical instrument also called as Cooing Dove murmur. Can also occur in acute myocardial infarction and acute rheumatic fever.
Murmur of mitral regurgitation
Typical murmur of mitral regurgitation

  • High pitched
  • Soft blowing
  • Pansystolic murmur
  • Best heard with diaphragm of stethoscope
  • Patient in left lateral position
  • At the height of expectation
  • The murmur radiate towards the left axilla and inferior angle of scapula
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Heartsounds in mitral regurgitation

What are the causes of soft S1 in mitral regurgitation
  • It is due to the incomplete opposition of valve cusps
  • There is partial closure of mitral valve orifice at the onset of ventricular systoli
Causes of loud S1 in MR
  • Co-existing mitral stenosis
  • MVP – MR
  • MR due to papillary muscle dysfunction
What are the causes of left ventricular S3 in MR
  • It is due to elevated left ventricular end diastolic volume (LVEDV)
  • Due to left ventricular dysfunction – LV dysfunction 


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What are the important cause of mitral regurgitation ?

Mitral regurgitation can occur secondary to lesion of mitral annulus, chordac, papillary muscle, left ventricular lesions. 
Caspal lesions
  • Rheumatoid heart disease
  • Mild valve pro-lapse
  • Infective endocarditis
  • Trauma
Annular lesions 
  • Dilatation of annulus – Dilated cardiomyopathy ,Ischemic heart disease
  • Annular calcification
Chordal lesions
  • Mitral valve prolapse
  • Infective endocarditis
  • Trauma
Papillary muscle dysfunction
  • Myocardial infarction
  • Angina
Left ventricular lesions
  • Aneurysm
  • Hypertrophic cardiomyopathy
Connective tissue diseases associated with mitral regurgitations are 
  • Marfan syndrome
  • Ehler Danlos syndrome
  • Rheumatoid arthritis
Related topics
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What are the clinical signs in mitral regurgitation?

Mitral regurgitation is associated with following clinical findings
Pulse : Normal or hyperkinetic pulse, Atrial fibrillation may be present, normal pulse pressure
JVP : Normal or raised
Apex beat : Forceful
Apical systolic thrill is felt
Late left parasternal heave
Soft S-1
Loud P2 (if PAH+)
Left ventricular S3
Flow murmur (MDM) at mitral area
High pitched blowing pansystolic murmur is heard in mitral area that is conducted to axilla / base of heart

Describe  the pulse in mitral regurgitation
In mild MR – Normal
Moderate to severe MR -  Hyperkinetic
Irregulary irregular in atrial fibrillation
Peripheral pulse may be absent in embolism due to atrial fibrillation.
Describe the JVP in mitral regurgitation
Usually normal
Prominent a wave is seen in PAH (pulmonary artery hypertension); prominent V wave seen in tricuspid regurgitation
Describe the apex beat in mitral regurgitation
Usually apex beat is forceful in MR. In moderate to severe MR due to associated cardiomegaly apex beat is shifted down and out.
Describe the type of LPH (left parasternal heave) in MR
Enlarged left atrium produce late systolic lift and pulmonary artery hypertension produce pansystolic lift.


Related topics
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What are the cardinal signs of mitral stenosis ?

Following are the physical examination signs in mitral stenosis
1.      Normal or low volume pulse : Atrial fibrillation may be present.
2.      Normal to low pulse pressure
3.      Normal or raised jugular venous pressure
4.      Tapping apex beat present
5.      S1 palpable
6.      Apical diastolic thrill
7.      Loud S1
8.      Loud P2 (if PAH – pulmonary artery hypertension is present)
9.      Opening snap present
10.  Rough and rumbling low pitched middiastolic murmur with presystolic accentuation heard in mitral area.
 The cardinal features are 
1.     Tapping apex
2.     Diastolic thrill
3.     Loud S1
4.     Opening snap
5.     MDM with presystolic accentuation
     Describe pulse in atrial fibrillation
1.     Usually pulse normal
2.     Low volume in severe MS
3.     Irregularly irregular in AF
4.     Peripheral pulses can be absent due to embolism as a result of atrial fibrillation.
     Why the apex is tapping in mitral stenosis
It is due to loud palpable S1
Loud S1 indicate pliable anterior mitral leaflet usually apex beat is in normal position.  If apex goes outward indicate RVH ,  it is downward and outward in LVH then think of    other causes such as MR, AR, AS, systemic HTN. Diffuse apex beat is present in RVH.

 
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How will you assess the severity of aortic stenosis

Clinical features that help in assessing the severity of aortic stenosis are
1.    Pulse
2.    Split of S2
3.    S4
4.    Length of murmur
5.    Peaking of murmur
6.    Loudness of murmur
7.    Thrill
Severity is based on
1.    Splitting of S2
Mild AS         - A2is followed by P2
Moderate AS - A2 is delayed resulting in single S2
Severe AS    - P2 - A2 reverse splitting of S2
2.    Presence of S4 and absent A2
3.    Presence of S3
4.    Long murmur and late peaking of murmur
5.    According to valve surface area
6.    According to gradient across the valve
Severity
Features
Mild AS
Murmur
Moderate AS
1.    Anacrotic pulse
2.    Thrill
3.    Long murmur
4.    Loud murmur
5.    Late peaking
Severe
1.    Anacrotic pulse
2.    Thrill
3.    Long murmur
4.    Late peaking
5.    Loud murmur
6.    Paradoxic split
7.    LVS­4
Severity based on valve area
1.    Normal valve area   : 2.5 – 3.5cm2
2.    Tight (critical AS )   : <0.5cm2 / m2 body surface are -0.8cm.
Severity of AS based on hemodynamic gradient
It is based on gradient across the valve
1.    Mild AS         : 25-50mm Hg
2.    Moderate AS : 50-75mmHg
3.    Severe AS     : >75mm/Hg
Severity of aortic stenosis is assessed with
1.    Low volume slow raising pulse
2.    Systolic decapitation of blood pressure
3.    Paradoxical splitting of S2
4.    Presence of S4
5.    If there is absent thrill is it is against a severe stenosis.

Read related topics  - Aortic Stenosis


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Heart sounds in Aortic stenosis

First heart sound in AS
S1 is normal or decreased intensity.
It is due to partial closure of mitral valve in presystole. Lound S1 is associated with MS.
A2 in AS
          Loud A2 indicate pliable valve cusp in congenital AS.
          Soft A2 – Occur due to rigid calcific valve.
Comment on split in AS
          Split may be normal.
          Paradoxical split or single S2 can occur.
When will you get normal split in AS
          Occur in mild to moderate AS.
          Split is normal even in congenital MS.
What is the significance of paradoxic split in AS
          Paradoxic split indicate severe AS if there no left bundles branch block (LLBB) . LV dysfunction seen in only 25% of elderly with severe AS.
          Paradoxical split is due to prolonged electromechanical systole which produce delay in A2 component.
What is the significance of single S2 in AS
         Seen in 66% of elderly with severe AS. It is due to absent A2 or due to masked P2 by the murmur. 
Significance of S4 inAS
          It indicate severe AS in the absence of coronary artery disease or hypertension. Palpable S4 always indicate severe AS.
Aortic ejection click
1.    AEC indicate valvular AS with mobile valves.
2.    AEC is common in congenital AS, and bicuspid aortic valve.
3.    It is rare in elderly.
4.    It disappear with valve calcification.
5.    AEC does not correlate with severity of AS.
6.    Amplitude correlate with that of A2.
What are the features of AEC
1.    AEC  occur after S1.
2.   It is best heard at the apex/ aortic area.
3.    There is no variation with respiration.
4.    It is a high pitched sound.
What is AEC
          It is a high pitched sound produced due to the snapping open of the stenotic thickened aortic valve.
Significance of aortic ejection click
1.    It indicate that the stenosis is at valvular level.
2.    The severity of AS is mild.
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Pulse in aortic stenosis

Aortic stenosis is characterized by slow rising pulse with a delayed sustained peak.
          The pulse is called anacrotic pulse (pulses parvus et tardus) . If there is pulses bisferiens that rules out predominant aortic stenosis.
What is the significance of pulse in AS
          If there is normal pulse in adult <60yrs with a normal left ventricular function that rules out moderate to severe aortic stenosis.
What are the factors that affect pulse in AS
1.    Age.
2.    Hypertension.
3.    Hypovolemia.
4.    Left ventricular function.
5.    Presence of pulmonary artery hypertension (PAH).
6.    Mitral valve disease.
7.    Aortic regurgitation.
What are the factors that exaggerate the low pulse volume in AS
1.    Hypovolemia.
2.    Cardiac failure.
3.    Pulmonary artery hypertension.
4.    Associated severe MS (Mild stenosis).
What are the factors which will apparently normalise the pulse in AS
1.    Hypertension.
2.    Presence of aortic regurgitation.
3.    Elderly age.
4.    Young age.
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Differentiate between valvular, supravalvular, subvalvular aortic stenosis

The clinical findings of valvular aortic stenosis are presence of ejection click and sott A2
Clinical signs in subvalvular AS are given below
  1. There is early diastolic murmur of AR.
  2. Heart size is larger.
  3. No ejection click or post stenotic dilatation of aorta.

Supravalvular AS signs are
  1. Systolic BP of right  arm is more than left arm.
  2. Thrill is more obvious than other types of AS and is conducted to carotids.
  3. No ejection click, A2 is normal or accentuated no post stenotic dilation of aorta.

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What are the clinical examination findings Aortic Stenosis (AS)

Clinical examination reveal the following signs in AS.
1.    Anacrotic pulse.
2.    Low  pulse pressure.
3.    Normal or raised JVP.
4.    Heaving apex-beat.
5.    Basal systolic thrill.
6.    Left parasternal heave if pulmonary artery hypertension is present.
7.    Loud P2 if PAH+.
8.    Paradoxical splitting of S2.
9.    LVS4.
10. Ejection click at apex.
11. Low pitched rough crescendo – descresendo ejection systolic murmur at the aortic area / apex that is conducted to the carotids.
So the signs are
1.    Anacrotic pulse.
2.    Heaving apex.
3.    Systolic thrill at the 2nd right intercostal space.
4.    Soft A2 with paradoxic split.
5.    Aortic ejection click.
6.    Ejection systolic murmur.
What is the blood pressure in aortic stenosis
Low pulse pressure is seen in AS.
If the systolic BP > 200mmHg - It exclude severe AS.
If the systolic BP >140mm/Hg - There will be coexistent aortic regurgitation or hypertension. 
What is the JVP in AS
          JVP is usually normal in AS.
Prominent a wave may occur due to - Bern Hein effect.
Bernhein effect
          In aortic stenosis there is hypertrophy of interventricular septum which bulge into right ventricle producing prominent a wave in JVP.
What are the palpating finding in AS
1.    Hearing apex.
2.    Palpable S4.
3.    Systolic thrill in 2nd RICS.
Comment on the apex beat in AS
Usually heaving apex is seen in AS. There is no displacement. Displaced apex beat may be there in AS due to coexisting aortic or mitral regurgitation and in let ventricular dysfunction.
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