residents report

Residents ReportResidents Report

Wednesday November 30, 2005Wednesday November 30, 2005

Jason Ryan, MDJason Ryan, MD

Valve Projection AreasValve Projection Areas

Cardiac AuscultationCardiac Auscultation

MurmursMurmurs– SystolicSystolic

EjectionEjection – Implies either obstruction or high output – Implies either obstruction or high output– Obstruction: AS, HOCM, rarely PSObstruction: AS, HOCM, rarely PS– High output: Anemia, Thyrotoxicosis, AR, ASD, VSDHigh output: Anemia, Thyrotoxicosis, AR, ASD, VSD– Innocent murmur: Mid-systolic, best at LSB, non Innocent murmur: Mid-systolic, best at LSB, non

radiatingradiating

PansystolicPansystolic – Implies retrograde flow from high to – Implies retrograde flow from high to low pressure chamberlow pressure chamber

– MR, TR, VSDMR, TR, VSD

Cardiac AuscultationCardiac Auscultation

MurmursMurmurs– DiastolicDiastolic

Retrograde flow across incompetent valveRetrograde flow across incompetent valve– AR, PRAR, PR

Diastolic fillingDiastolic filling– MSMS

The 6 “Must Know” MurmursThe 6 “Must Know” Murmurs

1.1. Aortic StenosisAortic Stenosis

2.2. HOCMHOCM

3.3. Mitral RegurgitationMitral Regurgitation

4.4. Mitral StenosisMitral Stenosis

5.5. Aortic RegurgitationAortic Regurgitation

6.6. Tricuspid RegurgitationTricuspid Regurgitation

Aortic StenosisAortic Stenosis

Systolic ejection murmur that usually peaks in early systoleSystolic ejection murmur that usually peaks in early systole– Location: Classically heard best in right 2Location: Classically heard best in right 2ndnd interspace interspace– As the degree of AS worsens, the murmur peaks closer to S2 As the degree of AS worsens, the murmur peaks closer to S2

(i.e. later).(i.e. later).– In general, the later the peak and the louder the murmur, the In general, the later the peak and the louder the murmur, the

more severe the stenosis.more severe the stenosis.

Often radiates to the carotidsOften radiates to the carotids– Carotid upstrokes are Carotid upstrokes are delayeddelayed!!

In reality, often loudest in a “sash” or “shoulder harness” area In reality, often loudest in a “sash” or “shoulder harness” area from second right interspace to apexfrom second right interspace to apex

HOCMHOCM

Caused by outflow tract obstructionCaused by outflow tract obstruction

Location: 3Location: 3rdrd or 4 or 4thth left interspaces left interspaces

Can sound just like AS unless you do Can sound just like AS unless you do maneuvers!maneuvers!– Increasing size of LV makes murmur softerIncreasing size of LV makes murmur softer

Squatting (raises BP)Squatting (raises BP)

– Decreasing size of LV makes murmur louderDecreasing size of LV makes murmur louderValsalva (Valsalva (↑intrathoracic pres↑intrathoracic pres ↓VR ↓VR↓LV)↓LV)

– Valsalva: HOCM gets louder, AS gets softerValsalva: HOCM gets louder, AS gets softer– Squatting: HOCM gets softer, AS gets louderSquatting: HOCM gets softer, AS gets louder

Mitral RegurgitationMitral Regurgitation

Holosystolic murmur Holosystolic murmur

Location: Heard best at the apexLocation: Heard best at the apex

– Radiates to the axillaRadiates to the axilla

Pearl: Presence of S3 suggest severe MRPearl: Presence of S3 suggest severe MR

Bonus trivia: What is the Gallavardin phemonena?Bonus trivia: What is the Gallavardin phemonena?

Mitral StenosisMitral Stenosis

Causes either (or both) an opening snap or a Causes either (or both) an opening snap or a diastolic rumble. diastolic rumble.

Location: apexLocation: apex

More bonus (read: useless) trivia: What is the More bonus (read: useless) trivia: What is the Austin Flint murmur?Austin Flint murmur?

Aortic RegurgitationAortic Regurgitation

Early diastolic murmur. “Blowing.”Early diastolic murmur. “Blowing.”– Often associated with systolic ejection murmur from high Often associated with systolic ejection murmur from high

stroke volumestroke volumeLocation: Heard best at LSB in 3Location: Heard best at LSB in 3rdrd or 4 or 4thth IC space IC spaceWide pulse pressureWide pulse pressure

Tricuspid RegurgitationTricuspid Regurgitation

Holosystolic murmurHolosystolic murmur

Causes: RV failure and dilation, Causes: RV failure and dilation, Pulmonary hypertension of any causePulmonary hypertension of any cause

Location: Heard best at left lower sternal Location: Heard best at left lower sternal bordererborderer

Clues: Clues: – Intensity may increase with inspirationIntensity may increase with inspiration– Look for large v waves in neck veinsLook for large v waves in neck veins

PearlsPearls

PDAPDA– Continuous, “machine-like” murmurContinuous, “machine-like” murmur

ASDASD– Fixed split S2Fixed split S2

VSDVSD– Usually a pansystolic murmurUsually a pansystolic murmur

AV DissociationAV Dissociation– Cannon AV waves, pounding in neckCannon AV waves, pounding in neck

MVPMVP– Mid-systolic click Mid-systolic click

different from an opening snap which is diastolicdifferent from an opening snap which is diastolic

PearlsPearls

S1 S2 S1 A2P2

Normal heart sounds:

Inspiration causes “physiologic splitting”

PearlsPearls

S1 S2 S1 A2P2


A Right Bundle Branch Block delays P2 causing a “widely split S2” which is a persistent split that widens with inspiration:

S1 A2 P2S1 A2P2

PearlsPearls

S1 S2 S1 A2P2


A Left Bundle Branch Block delays A2 causing a “paradoxically (or reversed) split S2” which is a split that occurs with expiration and disappears with inspiration:

S1 S2S1 P2A2

Question 1Question 1

1. A 60-year old man has a 2-month history of 1. A 60-year old man has a 2-month history of progressive dyspnea and chest pain. Cardiac progressive dyspnea and chest pain. Cardiac auscultation reveals a grade 3 systolic ejection auscultation reveals a grade 3 systolic ejection murmur that is heard best at the second right murmur that is heard best at the second right interspace. The murmur radiates into the carotid interspace. The murmur radiates into the carotid arteries. What is the most likely underlying arteries. What is the most likely underlying valvular abnormality?valvular abnormality?

1. Aortic regurgitation 1. Aortic regurgitation 2. Aortic stenosis 2. Aortic stenosis 3. Mitral regurgitation 3. Mitral regurgitation 4. Mitral stenosis 4. Mitral stenosis

Answer 1Answer 1

Aortic stenosis. Systolic ejection murmurs Aortic stenosis. Systolic ejection murmurs are caused by outflow obstruction. Their are caused by outflow obstruction. Their intensity peaks in midsystole and is intensity peaks in midsystole and is described as a crescendo-decrescendo or described as a crescendo-decrescendo or “diamond-shaped” murmur. The murmur of “diamond-shaped” murmur. The murmur of aortic stenosis is an example of a systolic aortic stenosis is an example of a systolic ejection murmur. The murmur radiates ejection murmur. The murmur radiates along the outflow track (ie, into the carotid along the outflow track (ie, into the carotid arteries). arteries).


A 50-year-old woman has a 3-month history of A 50-year-old woman has a 3-month history of progressive dyspnea. Cardiac auscultation progressive dyspnea. Cardiac auscultation reveals a grade 3 pansystolic murmur heard reveals a grade 3 pansystolic murmur heard best at the apex. The murmur is medium-pitched best at the apex. The murmur is medium-pitched and radiates to the axilla. What is the most likely and radiates to the axilla. What is the most likely underlying valvular abnormality?underlying valvular abnormality?


Answer 2Answer 2

Mitral regurgitation. Pansystolic murmurs Mitral regurgitation. Pansystolic murmurs are almost always caused by reverse flow are almost always caused by reverse flow across a valve. The single exception across a valve. The single exception occurs in cases of a ventricular septal occurs in cases of a ventricular septal defect, in which blood flows across an defect, in which blood flows across an orifice in the septum. The murmur of mitral orifice in the septum. The murmur of mitral regurgitation radiates into the axilla in the regurgitation radiates into the axilla in the direction of the flow. direction of the flow.


A 40-year-old woman has a 3-month history of A 40-year-old woman has a 3-month history of progressive dyspnea. Cardiac auscultation reveals a progressive dyspnea. Cardiac auscultation reveals a grade 3 diastolic murmur heard best at the apex. The grade 3 diastolic murmur heard best at the apex. The murmur is low-pitched and has a rumbling quality. murmur is low-pitched and has a rumbling quality. There is a snapping sound that immediately There is a snapping sound that immediately precedes the murmur. What is the most likely precedes the murmur. What is the most likely underlying valvular abnormality?underlying valvular abnormality?


Answer 3Answer 3

Mitral stenosis. The murmur of mitral Mitral stenosis. The murmur of mitral stenosis is generated during left atrial stenosis is generated during left atrial contraction as blood is being forced contraction as blood is being forced through the narrowed mitral valve. There through the narrowed mitral valve. There is usually an opening snap just before the is usually an opening snap just before the diastolic rumble begins. diastolic rumble begins.


During a routine physical examination of a 30-year-old During a routine physical examination of a 30-year-old man, cardiac auscultation reveals a grade 3 systolic man, cardiac auscultation reveals a grade 3 systolic ejection murmur heard best at the left lower sternal ejection murmur heard best at the left lower sternal border. The murmur does not radiate into the carotid border. The murmur does not radiate into the carotid arteries and becomes louder when the patient is asked arteries and becomes louder when the patient is asked to perform the Valsalva maneuver. What is the most to perform the Valsalva maneuver. What is the most likely underlying cardiac abnormality?likely underlying cardiac abnormality?

1. Aortic stenosis 1. Aortic stenosis 2. Dilated cardiomyopathy 2. Dilated cardiomyopathy 3. Hypertrophic cardiomyopathy 3. Hypertrophic cardiomyopathy 4. Mitral regurgitation 4. Mitral regurgitation

Answer 4Answer 4

Hypertrophic cardiomyopathy. Systolic Hypertrophic cardiomyopathy. Systolic ejection murmurs are caused by outflow ejection murmurs are caused by outflow obstruction. In this case, the obstruction of obstruction. In this case, the obstruction of the outflow tract results from asymmetrical the outflow tract results from asymmetrical hypertrophy of the ventricular septum. The hypertrophy of the ventricular septum. The murmur is worsened with performance of murmur is worsened with performance of the Valsalva maneuver, because the the Valsalva maneuver, because the outflow obstruction is increased. outflow obstruction is increased.


During a routine physical examination of a 15-During a routine physical examination of a 15-year-old boy, cardiac auscultation reveals a year-old boy, cardiac auscultation reveals a grade 3 systolic ejection murmur heard best at grade 3 systolic ejection murmur heard best at the left second interspace. S2 is widely split and the left second interspace. S2 is widely split and fixed (ie, does not vary with respirations). What fixed (ie, does not vary with respirations). What is the most likely underlying cardiac is the most likely underlying cardiac abnormality?abnormality?

Atrial septal defect Atrial septal defect Ventricular septal defect Ventricular septal defect Aortic stenosis Aortic stenosis Pulmonic stenosis Pulmonic stenosis

Answer 5Answer 5

Atrial septal defect. The systolic ejection Atrial septal defect. The systolic ejection murmur produced by an atrial septal murmur produced by an atrial septal defect results from increased flow across defect results from increased flow across the pulmonic valve. The right ventricle has the pulmonic valve. The right ventricle has increased filling as blood is shunted from increased filling as blood is shunted from the left atrium to the right atrium and finally the left atrium to the right atrium and finally into the right ventricle. There is fixed into the right ventricle. There is fixed splitting of S2 because of continued delay splitting of S2 because of continued delay in the closure of the pulmonic valve. in the closure of the pulmonic valve.


A 20-year-old female is evaluated for palpitations. She has noticed A 20-year-old female is evaluated for palpitations. She has noticed rapid pounding in her chest on several occasions. She is most rapid pounding in her chest on several occasions. She is most aware of pounding in her neck. Most episodes last less than 1 aware of pounding in her neck. Most episodes last less than 1 minute, but a few have lasted one half hour. During an episode she minute, but a few have lasted one half hour. During an episode she is lightheaded, but does not have syncope, chest pain, or shortness is lightheaded, but does not have syncope, chest pain, or shortness of breath. Symptoms usually occur without warning at rest. If she of breath. Symptoms usually occur without warning at rest. If she breathes slowly and deeply, the episodes usually stop on their own. breathes slowly and deeply, the episodes usually stop on their own. Recently, the episodes have been more frequent. Her EKG and Recently, the episodes have been more frequent. Her EKG and physical exam are normal. physical exam are normal. Which is the most likely diagnosis?Which is the most likely diagnosis?– 1. Benign premature atrial contactions1. Benign premature atrial contactions– 2. Palpitations related to MVP2. Palpitations related to MVP– 3. Paroxysmal SVT3. Paroxysmal SVT– 4. Ventricular Tachycardia4. Ventricular Tachycardia– 5. Paroxysmal atrial flutter5. Paroxysmal atrial flutter

Answer 6Answer 6

Paroxysmal SVT. Aburpt onset and Paroxysmal SVT. Aburpt onset and regularity of patient’s symptoms suggest regularity of patient’s symptoms suggest SVT. The pounding in the neck is related SVT. The pounding in the neck is related to cannon A waves, caused by atrial to cannon A waves, caused by atrial contraction against a closed valve. PSVT contraction against a closed valve. PSVT in young women is usually AVNRT and is in young women is usually AVNRT and is much more common than than VT or much more common than than VT or Aflutter. Aflutter.


A 25-year-old pregnant woman is referred to you because of a heart A 25-year-old pregnant woman is referred to you because of a heart murmur noted during the second trimester of pregnancy (her first murmur noted during the second trimester of pregnancy (her first pregnancy). The patient has no history of cardiac disease and the pregnancy). The patient has no history of cardiac disease and the murmur was not noted during previous exams. She is murmur was not noted during previous exams. She is asymptomatic. Exam shows a mildly displaced apical impulse and asymptomatic. Exam shows a mildly displaced apical impulse and lower extremity edema. S1 and S2 are normal and an S3 is noted at lower extremity edema. S1 and S2 are normal and an S3 is noted at the apex. A grade 2/6 early to mid-peaking systolic murmur is the apex. A grade 2/6 early to mid-peaking systolic murmur is audible at the left sternal border. audible at the left sternal border. Which of the following is most likely?Which of the following is most likely?– 1. Bicuspid aortic valve with mild to moderate stenosis1. Bicuspid aortic valve with mild to moderate stenosis– 2. Congenitally abnormal pulmonary valve with moderate stenosis2. Congenitally abnormal pulmonary valve with moderate stenosis– 3. Physiologic murmur related to pregnancy3. Physiologic murmur related to pregnancy– 4. Mitral valve regurgitation related to MVP4. Mitral valve regurgitation related to MVP– 5. Bicuspid aortic valve with moderate regurgitation5. Bicuspid aortic valve with moderate regurgitation

Answer 7Answer 7

Physiologic murmur related to pregnancy. Physiologic murmur related to pregnancy. S3 is audible in 80% of pregnant women. S3 is audible in 80% of pregnant women. An early peaking ejection systolic murmur An early peaking ejection systolic murmur (flow murmur) is audible in 90% of (flow murmur) is audible in 90% of pregnant women. Apical displacement is pregnant women. Apical displacement is common because of the increase in blood common because of the increase in blood volume the occurs in later pregnancy. volume the occurs in later pregnancy.


A 26-year-ol man seeks your advice because he was A 26-year-ol man seeks your advice because he was diagnosed as having a heart murmur as a baby. At that diagnosed as having a heart murmur as a baby. At that time, his parents were told he would “outgrow” the time, his parents were told he would “outgrow” the murmur. The patient participates actively in sports murmur. The patient participates actively in sports without any cardiac symptoms. On physical exam, S1 is without any cardiac symptoms. On physical exam, S1 is normal, S2 is physiologically split. A thrill is noted in the normal, S2 is physiologically split. A thrill is noted in the third left intercostal space and a 4/6 holosytolic murmur third left intercostal space and a 4/6 holosytolic murmur is noted along the left sternal border radiating to the is noted along the left sternal border radiating to the right. No S3 or S4 are heard.right. No S3 or S4 are heard.Which of the following is most likely?Which of the following is most likely?– 1. Aortic stenosis1. Aortic stenosis– 2. Mitral regurgitation related to MVP2. Mitral regurgitation related to MVP– 3. VSD3. VSD– 4. Cardiomyopathy4. Cardiomyopathy

Answer 8Answer 8

VSD. VSD’s create VSD. VSD’s create very loudvery loud heart heart murmurs that are holosystolic (often they murmurs that are holosystolic (often they also cause a thrill). None of the other also cause a thrill). None of the other answers fit with the exam. answers fit with the exam.


A 42-year-old woman comes to your office for evaluation A 42-year-old woman comes to your office for evaluation of angina and dyspnea on exertion for 6 months. She of angina and dyspnea on exertion for 6 months. She has no cardiac history other than a long standing has no cardiac history other than a long standing murmur. On physical exam, she has a normal S1 and murmur. On physical exam, she has a normal S1 and S2. An S4 is noted. She has a grade 2/6 late-peaking S2. An S4 is noted. She has a grade 2/6 late-peaking systolic ejection murmur that increases with valsalva as systolic ejection murmur that increases with valsalva as well as when she rises from squatting to standing. well as when she rises from squatting to standing. Which of the following is most likely?Which of the following is most likely?– 1. Aortic Stenosis1. Aortic Stenosis– 2. HOCM2. HOCM– 3. Mitral Regurgitation3. Mitral Regurgitation– 4. VSD4. VSD

Answer 9Answer 9

HOCM. Angina and dyspnea are HOCM. Angina and dyspnea are symptoms of progressive obstruction. symptoms of progressive obstruction. While this can also be cause by AS, a While this can also be cause by AS, a murmur that increases with valsalva (i.e. murmur that increases with valsalva (i.e. deceased preloaddeceased preloaddecreased LV size) is decreased LV size) is consistent with HOCM. consistent with HOCM.

Welcome to the Applicants!Welcome to the Applicants!

The End. The End.

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