1、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 au
2、scultation,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. noise Ventricular se
3、ptal defect;,Small hole;High pressure maintained between LV and RV throughout systole.High velocity flow, all through systole.Big noise, all through systole,Clinical vs. noise Ventricular septal defect;,Big hole;Pressure quickly equalises between LV and RV.High volume flow, but no great velocity and
4、 only at beginning of systole.Little noise, early systole only,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 retur
5、n 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
6、Symptoms Clinical signs,Aortic stenosis,Aortic stenosis,Aortic stenosis,HaemodynamicsLeft 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,Aor
7、tic Stenosis,Aortic stenosis,Haemodynamics Massively increased LV pressures Low systemic pressureSymptoms 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 Systoli
8、c 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
9、 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 Mussets sign Duroziezs sign Large volume, collapsing pulse Apex d
10、isplaced, 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 i
11、nto lungs, R heartClinical 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 heartClinical Atrial arrhythmias, potentia
12、lly 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 Radiat
13、ion 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 Increas
14、ed pressure in lungs and R heartClinical 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
15、 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 IM
16、PORTANT 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 illnes
17、s, 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 WorldImportant part of any introductory history.,What happens if something goes wrong,Nothing! Compensation over man
18、y years Haemodynamics slowly worsen Patient feels “old” Breathless Tired all the time Chest painFinal decompensation,Acute mitral regurgitation Acute ventricular septal defect Infective endocarditis leading to valve destructionAcute valvular changes are much less well tolerated than chronic disease,
19、 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 catheterisationRegular assessment of patient,Echocardiography,Ultrasound examination of the heart and g
20、reat 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
21、-arrhythmics Aspirin or anticoagulation Surgery Percutaneous Open surgery,Valve surgery,Alter the native valve Valvotomy Open repairReplace the valve Homograft Xenograft Metalic valve,Xenograft,Do not require anticoagulationCan degenerate,Metallic valve,Do require anticoagulation; INR often 3.0Appar
22、ently last for ever!Audible valve clicks,Infective endocarditis,Infection on a heart structure Usually an already abnormal valve Can be any other structure or abnormalityUsually bacterial Can be fungalOverall mortality 20%,Infective endocarditis,Presents as generalised sepsis Fevers, night sweats, w
23、eight loss New murmur Raised inflammatory markers Positive blood cultures“Duke Criteria” for diagnosis. +ve blood cultures, endocardial involvement Predisposition, fever, vascular phenom, serological tests, etc.,Infective endocarditis,Commonly; Prosthetic valve Prior endocarditis Aortic valve diseas
24、e 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 involvementMIN
25、OR CRITERIA Predisposition Fever Vascular phenomena Immunological phenomena Microbiological evidence Echocardiographic evidence,Diagnosis;2 major 1 major + 3 minor 5 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,
