During this week’s episode, we’ll be discussing valvular disorders, in essence, heart murmurs.

There are LOADS of Picmonics available for heart murmurs. A couple of my favorites Mitral Regurgitation and Aortic Stenosis.

Systole=ventricles contracting

Diastole=ventricles relaxing & refilling

S1=beginning of systole. AV valves (mitral & tricuspid) are closing. “lub”

S2=end of systole. Semilunar valves closing (aortic & pulmonic) “dub”

Lub, dub, rest, lub, dub, rest

 

Murmur Accentuation Maneuvers

The following applies to all murmurs except that of hypertrophic cardiomyopathy, in which the opposite is true

* Position:

* Aortic=increased with leaning forward

* Mitral=LLD

* Increased venous return

* Squatting

* Leg raise

* Lying down

* Later click in MVP

* Inspiration

* Right sided murmurs only

* Also due to increased venous return

* Expiration

* Left sided murmurs only

* Also due to increased venous return

* Increased Afterload

* Handgrip

* Increases regurgitation murmurs

* Pushes backward

Aortic Stenosis

* #1 valvular disease

* Etiologies:

* Calcification

* Bicuspid valve (if under 70y.o.)

* Systolic, crescendo-descrescendo ejection murmur

* At right upper sternal border (the location of the aortic valve)

* With radiation to the carotids

* Narrowed pulse pressure

* Pulsus parvus et tardus

* Small, delayed, carotid pulse

* Not specific to aortic stenosis

* Can lead to angina, syncope, LVH, and CHF

* Tx:

* VALVE REPLACEMENT

* Once symptomatic

* Mechanical valves (vs bioprosthetic) require lifelong anticoagulation

Mitral Stenosis

* Etio: rheumatic heart disease

* Early mid-diastolic rumble preceded by an opening snap

* At apex (location of mitral valve)

* Increased in left lateral decubitus position

* Prominent S1 (stenotic mitral valve closes forcefully)

* Symptoms

* Pulmonary symptoms

* Blood backs into lungs

* Pulmonary htn

* Atrial fibrillation

* 2/2 atrial enlargement

* “mitral facies”

* Flushed cheeks with facial pallor

* Treatment:

* Percutaneous balloon valvuloplasty

* Younger patients

* Non-calcified valves

* Valve replacement otherwise

Mitral Regurgitation

* Etio:

* mitral valve prolapse #1

* papillary muscle dysfunction

* ischemia/infarction

* Blowing, holosystolic murmur

* At Apex (location of mitral valve)

* Radiation to axilla

* Blowing=regurg

* Widely split S2

* Aortic valve closes early due to decreased LV ejection time

* Pulmonic valve closes late due to pulmonary htn (increased pressure to overcome)