Valvular heart disease and cardiac murmurx

Presenter: R4 陳彥旭
The Washington Manual of Medical Therapeutics, 33rd Edition
Braunwald’s Heart Disease A Textbook of Cardiovascular Medicine,
Ninth Edition 2011
Result from audible vibrations caused by increased
turbulence
The magnitude, dynamic variability, and duration of
the pressure difference between two cardiac chambers,
or between the ventricles and their respective great
arteries
Intensity(Gr I-VI), period, frequent, configuration,
location, radiation, response to bedside maneuvers
Systolic murmur
Diastolic murmur
Aortic
Obstructive
Supravalvular—supravalvular aortic stenosis, coarctation of the
aorta
Valvular—AS and aortic sclerosis
Subvalvular—discrete, tunnel, or HOCM
Increased flow, hyperkinetic states, AR, complete heart block
Dilation of ascending aorta, atheroma, aortitis
Pulmonary
Obstructive
Supravalvular—pulmonary artery stenosis
Valvular—pulmonic valve stenosis
Subvalvular—infundibular stenosis (dynamic)
Increased flow, hyperkinetic states, left-to-right shunt (e.g., ASD)
Atrioventricular valve regurgitation (MR, TR)
Left-to-right shunt at ventricular level (VSD)
Mitral—MVP, acute myocardial ischemia
Tricuspid—TVP
Aortic regurgitation
Valvular—congenital (bicuspid valve), rheumatic
deformity, endocarditis, prolapse, trauma,
postvalvulotomy
Dilation of valve annulus—aortic dissection,
annuloaortic ectasia, cystic medial degeneration,
hypertension, ankylosing spondylitis
Widening of commissures—syphilis
Pulmonic regurgitation
Mitral
Mitral stenosis
Carey Coombs murmur (mid-diastolic apical murmur
in acute rheumatic fever)
Increased flow across nonstenotic mitral valve (e.g., MR,
VSD, PDA, high-output states, complete heart block)
Tricuspid
Severe or eccentric AR (Austin Flint murmur)
Presystolic accentuation of mitral stenosis murmur
Austin Flint murmur of severe or eccentric AR
PDA
Coronary AV fistula
Ruptured sinus of Valsalva aneurysm
Aortic septal defect
Cervical venous hum
Anomalous left coronary artery
Proximal coronary artery stenosis
Mammary souffe of pregnancy
Pulmonary artery branch stenosis
Bronchial collateral circulation
Small (restrictive) ASD with MS
Intercostal AV fistula
Frequent
High frequent- AS, AR, MR
Low frequent- MS, S3, S4
Respiration
Right side murmur increase with inspiraton
Left side murmur are louder during expiration
Squatting abruptly or rapid standing
Most murmur increase in length and intensity with
squatting abruptly with two exception: MVP and
HOCM
In patient with MVP, the click and murmur will move
away from S1 with squatting due to the delay in onset of
leaflet prolapse at higher ventricular volumes
HOCM
Valsalva maneuver
Most murmur decrease in length and intensity with two
exception: MVP and HOCM
Maneuver that change LV afterload
Intensity of MR, VSD, AR increase with Increasing LV
afterload(handgrap, vasopressor) and decrease after
exposure to vasodilating agents
Isotonic or isometric(handgrip)exercise
Murmur cause by blood flow across normal or
obstructed valves such as AS ans PS became louder
Etiology
Organic MR- rheumatic, degeneration, endocarditis
Functional MR- dilated cardiomyopathy, ischemic MR
DOE, palpitation due to atrial arrhythmia, fatigue,
volume overload
Pansystolic(holosystolic) blowing murmur over apex
with radiation to left axilla
ECG- LAE, LVH/LV enlargement, Af
CXR- enlarged LA, pulmonary edema, enlarged
pulmonary artery, cardiomegaly
Transthoracic echocardiography- access etiology and
severity of MR, LVEF, chamber size
TEE, 3D echo, stress echo, cardiac catheterization,
MRI, nuclear, CTA
Afterload reduction and surgery for acute MR
ACE-I and ARB for functional MR
Surgical management
Acute severe MR
Chronic severe MR with symptom, without severe LV
dysfunction(LVEF< 30%) or LVESD > 55 mm
Chronic severe MR without symptom, but LVEF: 3060% , or LVESD> 40 mm
Mitral clip
Etiology
Rheumatic- associated with MR
SLE, rheumatoid arthritis, congenital, mitral annulus
calcification, etc
Dyspnea, orthopnea, decreased function capacity,
PND, fatigue, palpitation due to Af, systemic
embolism, hemoptysis, chest pain
Mid-diastolic rumbling murmur with OS over apex
Presystolic murmur over apex
Accentuated M1 and P2
A2-OS interval varies inversely with the severity of
stenosis
ECG- LAE, Af, RVH
CXR- LAE, enlarged RA/RV
TTE- access etiology, mitral valve area, mean
transmitral pressure gradient
TEE- presence or absence of clot, severity of MR
Cardiac catheterization
Severe MS: mean gradient > 10 mmHg, PASP> 50
mmHg, valve area < 1.0 cm^2
Diuretics, low salt diet
Rate control with beta-blocker and CCB for Af with
RVR
Anticoagulant therapy
MS with Af
MS and prior embolic event
MS with left atrial thrombus
PTMV(percutaneous transluminal mitral
valvuloplasty )
Symptomatic with moderate to severe MS without LA
thrombus or moderate-to-severe MR
Asymptomatic with moderate to severe MR in those
who have PH(PASP>50 mmHg)
Surgical management
When PTMV is unavailable, or contraindicated due to
LA thrombus or moderate to severe MR
Reserved for those who are not candidates for PTMV
Etiology
Aortic valve- rheumatic disease, calcific degeneration,
infective endocarditis,
Aortic root- Marfan’s syndrome, ascending aortic
dissection, syphilitic aortitis
Symptoms of cardiogenic shock, dyspnea, fatigue,
angina, decrease exercise tolerance
To-and-fro murmur over RUSB with radiation to LSB
and apex
Austin Flint murmur
Widened pulse pressure
ECG- LVH, LAE
TTE- LV systolic function, LV dimension, leaflet
number and morphology, etiology of AR
TEE- more accurate for aortic dissection then TTE
Medical therapy- limited role
Vasodilator to reduced systolic blood pressure in
hypertensive patient, in heart failure patient
Surgical management(AVR)
Symptomatic with severe AR
Asymptomatic with chronic severe AR and LV systolic
dysfunction(EF<50%)
Etiology
Calcific/ degenerative
Bicuspid
Rheumatic
Classic triad- angina, heart failure, syncope
Harsh systolic ejection(crescendo-decrescendo)
murmur over RUSB with radiation to both neck
Pulsus parvus and pulsus tardus
ECG- LAE, LVH
CXR- LVH, cardiomegaly
TTE- transvalvular mean and peak gradients
Severe AS- peak jet velocity> 4.0 m/s, mead gradient>
40 mmHg, valve area< 1.0 cm^2
TEE, cardiac catheterization
No medical treatment proven to decrease mortality or
delay surgery
Treat hypertension, careful use of diuretics
Avoid venodilator or negative inotropes(beta-blocker,
CCB)
IABP
Surgical management
Symptomatic severe AS
Asymptomatic severe AS patient undergoing CABG or
OP for other valve
Asymptomatic severe AS and LV systolic
dysfunction(EF < 50%)
BAV(Balloon aortic valvuloplasty)- palliative
treatment or bridge to definite therapy, high
recurrent rate
TAVI(transcatheter aortic valve implantation)
Severe AS patient with high surgical risk or inoperable
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