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. noise Ventricular septal 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 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 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,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,Aortic 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 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 Mussets sign Duroziezs 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 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, 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 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 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”,