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Valvular heart disease cardiology club 11 18 2015
This document discusses cardiac murmurs and auscultation of heart valves. It begins by defining cardiac murmurs as audible turbulent sound waves that can indicate underlying valvular pathology. Murmurs can be systolic or diastolic and pathological or benign. Characteristics of different types of murmurs are provided. The document then discusses heart valves, causes of valve diseases, murmurs associated with specific valve lesions, heart sounds, and techniques for cardiac auscultation and murmur localization. Diagrams illustrate heart valve anatomy and abnormalities, as well as hemodynamics in valve diseases.
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Valvular heart disease cardiology club 11 18 2015
- 1. ABB MD FACCABBMD FACC©© 1 Heart Valves & Cardiac AuscultationHeart Valves & Cardiac Auscultation A. Bornstein, M.D., F.A.C.C.A. Bornstein, M.D., F.A.C.C. Assistant Professor of Science EducationAssistant Professor of Science Education Hofstra North Shore-LIJ School of MedicineHofstra North Shore-LIJ School of Medicine Hempstead, NYHempstead, NY
- 2. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Cardiac MurmursCardiac Murmurs • Auscultatory sound: cardiac or vascular origin ofAuscultatory sound: cardiac or vascular origin of short durationshort duration • Cardiac murmurs are audible turbulent sound waves in the range of 20-Cardiac murmurs are audible turbulent sound waves in the range of 20- 20,000 cycles/second; often,20,000 cycles/second; often, first signfirst sign of underlying valvular pathologyof underlying valvular pathology • May beMay be systolicsystolic oror diastolicdiastolic,, pathologicalpathological oror benignbenign • Systolic murmurs may be due to physiological increases inSystolic murmurs may be due to physiological increases in blood flowblood flow velocityvelocity or might indicate an as yetor might indicate an as yet asymptomaticasymptomatic cardiac diseasecardiac disease • Diastolic murmurs and most continuous murmurs are almostDiastolic murmurs and most continuous murmurs are almost alwaysalways pathologicalpathological and require further evaluationand require further evaluation • ECGECG && CXRCXR provide some limited diagnostic information and are readilyprovide some limited diagnostic information and are readily available testsavailable tests 2
- 3. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Characteristics of MurmursCharacteristics of Murmurs • Benign murmur:Benign murmur: - Early to mid peaking systolicEarly to mid peaking systolic - Soft (I-II/VI)Soft (I-II/VI) - Varies with respirationVaries with respiration - Presents during normal exam and work-upPresents during normal exam and work-up • Pathologic murmur:Pathologic murmur: - All diastolic murmursAll diastolic murmurs - All pansystolic murmurs (holosystolic murmurs)All pansystolic murmurs (holosystolic murmurs) - Late peaking systolic murmursLate peaking systolic murmurs - Very loud murmurs (III-V/VI)Very loud murmurs (III-V/VI) - Continuous murmursContinuous murmurs 3
- 4. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Grading of Heart Murmurs Grade I-Grade VIGrading of Heart Murmurs Grade I-Grade VI 4
- 5. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Turbulent Flow vs. Laminar FlowTurbulent Flow vs. Laminar Flow • Normally, blood flow is laminar; withNormally, blood flow is laminar; with flow velocityflow velocity across valve oracross valve or valve orificevalve orifice (stenosis), laminar flow(stenosis), laminar flow is disruptedis disrupted turbulenceturbulence murmur;murmur; blood does not flow linearly & smoothlyblood does not flow linearly & smoothly in adjacent layers; instead flow becomesin adjacent layers; instead flow becomes chaoticchaotic • TurbulenceTurbulence:: energy needed to driveenergy needed to drive blood flow because turbulenceblood flow because turbulence lossloss of energy as friction, (generates heat);of energy as friction, (generates heat); when plotting a pressure-flowwhen plotting a pressure-flow relationship, turbulencerelationship, turbulence perfusionperfusion pressure needed to drive a given flow;pressure needed to drive a given flow; at any given perfusion pressure,at any given perfusion pressure, turbulence leads toturbulence leads to in flowin flow • Magnitude of perfusionMagnitude of perfusion pressure gradientpressure gradient depends on severity ofdepends on severity of valve stenosisvalve stenosis andand flow rate orflow rate or flow velocityflow velocity V = Q/tV = Q/t Q = A VQ = A V
- 6. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Turbulent Flow vs. Laminar FlowTurbulent Flow vs. Laminar Flow • Normally, blood flow isNormally, blood flow is laminarlaminar;; withwith flowflow across valve oracross valve or valve orificevalve orifice (stenosis), laminar(stenosis), laminar flow is disruptedflow is disrupted turbulenceturbulence murmur; blood does not flow linearly &murmur; blood does not flow linearly & smoothly in adjacent layers; insteadsmoothly in adjacent layers; instead flow becomes chaoticflow becomes chaotic • Turbulence:Turbulence: energy needed to driveenergy needed to drive blood flow because turbulenceblood flow because turbulence lossloss of energy asof energy as frictionfriction, (generates, (generates heatheat); when plotting a pressure-); when plotting a pressure- flow relationship, turbulenceflow relationship, turbulence perfusion pressureperfusion pressure needed to drive aneeded to drive a given flow; at any givengiven flow; at any given perfusion pressure, turbulence leads toperfusion pressure, turbulence leads to in flowin flow • Magnitude of perfusionMagnitude of perfusion pressurepressure gradientgradient depends on severity ofdepends on severity of valvevalve stenosisstenosis and flow rate orand flow rate or flow velocityflow velocity
- 7. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Thoracic LandmarksThoracic Landmarks
- 8. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Thoracic LandmarksThoracic Landmarks
- 9. ABB MD FACCABBMD FACC©© Cardiac Timing CyclesCardiac Timing Cycles
- 10. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Examples of MurmursExamples of Murmurs • Benign:Benign: — Flow murmurFlow murmur • Pathologic:Pathologic: — Diastolic murmur: MS; TS; AI; PIDiastolic murmur: MS; TS; AI; PI — Pansystolic (holosystolic) murmur: MR; TR; VSDPansystolic (holosystolic) murmur: MR; TR; VSD — Loud murmurs: > III/VILoud murmurs: > III/VI — Continuous murmur: patent ductus arteriosus (PDA)Continuous murmur: patent ductus arteriosus (PDA) 12
- 11. ABB MD FACCABBMD FACC©© Phonocardiograms From Normal & Abnormal Heart SoundsPhonocardiograms From Normal & Abnormal Heart Sounds
- 12. ABB MD FACCABBMD FACC©© Murmurs, Extra Sounds, andMurmurs, Extra Sounds, and Cardiac Auscultation Timing CyclesCardiac Auscultation Timing Cycles
- 13. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Timing Auscultatory Events byTiming Auscultatory Events by Carotid Artery & Jugular Venous PulseCarotid Artery & Jugular Venous Pulse
- 14. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Murmurs by Position: Systolic MurmursMurmurs by Position: Systolic Murmurs • Right upper sternal border (RUSB)Right upper sternal border (RUSB) - Aortic stenosis (AS)Aortic stenosis (AS) • Left upper sternal border (LUSB)Left upper sternal border (LUSB) - Pulmonary insufficiency (PI)Pulmonary insufficiency (PI) • Left lower sternal border (LLSB)Left lower sternal border (LLSB) - Tricuspid regurgitation (TR)Tricuspid regurgitation (TR) - Ventricular septal defect (VSD)Ventricular septal defect (VSD) - Hypertrophic cardiomyopathy (HCM)Hypertrophic cardiomyopathy (HCM) • ApexApex - Mitral regurgitation (MR)Mitral regurgitation (MR) 16
- 15. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Murmurs by Position: Diastolic MurmursMurmurs by Position: Diastolic Murmurs • Left upper sternal border (LUSB)Left upper sternal border (LUSB) – Pulmonary insufficiency (PI)Pulmonary insufficiency (PI) • Left lower sternal border (LLSB)Left lower sternal border (LLSB) – Tricuspid stenosis (TS)Tricuspid stenosis (TS) • ApexApex – Mitral stenosis (MS)Mitral stenosis (MS) • 33rdrd intercostal space (ICS), lower sternal border (LSB)intercostal space (ICS), lower sternal border (LSB) – Aortic Insufficiency (AI)Aortic Insufficiency (AI) 17
- 16. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Continuous MurmursContinuous Murmurs • Require continuous pressure gradient for continuous blood flowRequire continuous pressure gradient for continuous blood flow • Occurs at artery-vein connectionsOccurs at artery-vein connections – Patent ductus arteriosus (PDA)Patent ductus arteriosus (PDA) – Arteriovenous malformation (AVM)Arteriovenous malformation (AVM) – Venous humVenous hum 18
- 17. ABB MD FACCABBMD FACC©© Aortic StenosisAortic Stenosis Aortic areaAortic area
- 18. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Aortic StenosisAortic Stenosis 20 Degenerative calcific aortic stenosisDegenerative calcific aortic stenosis Congenital aortic stenosisCongenital aortic stenosis (unicuspid valve)(unicuspid valve) Congenital aortic stenosisCongenital aortic stenosis (bicuspid valve)(bicuspid valve) Normal aortic valveNormal aortic valveNormal aortic valveNormal aortic valve
- 19. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Aortic Flow Murmur vs. Aortic StenosisAortic Flow Murmur vs. Aortic Stenosis Normal aortic valveNormal aortic valve with flow murmurwith flow murmur Stenotic aortic valveStenotic aortic valve with pathologic murmurwith pathologic murmur
- 20. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Summary of Systolic MurmursSummary of Systolic Murmurs
- 21. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Summary of Diastolic MurmursSummary of Diastolic Murmurs
- 22. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Pulse Characteristics: Normal & Aortic Valve DiseasePulse Characteristics: Normal & Aortic Valve Disease 3) Aortic insufficiency3) Aortic insufficiency 2) Aortic stenosis2) Aortic stenosis 1) Normal1) Normal Carotid pulseCarotid pulse Brachial pulse:Brachial pulse: combined AS & ARcombined AS & AR
- 23. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Valve Lesions & Hemodynamics (Aortic Stenosis)Valve Lesions & Hemodynamics (Aortic Stenosis) Normal pressuresNormal pressures Aortic stenosisAortic stenosis
- 24. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Aortic Stenosis & MurmurAortic Stenosis & Murmur Murmurs of aortic stenosisMurmurs of aortic stenosis Aortic stenosisAortic stenosis
- 25. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Aortic Stenosis & MurmurAortic Stenosis & Murmur Murmurs of aortic stenosisMurmurs of aortic stenosis Aortic stenosis hemodynamicsAortic stenosis hemodynamics
- 26. ABB MD FACCABBMD FACC©© 28 Early Ejection Click & Systolic Ejection MurmurEarly Ejection Click & Systolic Ejection Murmur Stenotic bicuspid aortic valve with ejection clickStenotic bicuspid aortic valve with ejection click
- 27. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© 29 Systolic Ejection Murmur: Severe Aortic StenosisSystolic Ejection Murmur: Severe Aortic Stenosis AorticAortic pressurepressure LVLV pressurepressure •Aortic stenosis is most often diagnosed while still asymptomaticAortic stenosis is most often diagnosed while still asymptomatic •Systolic crescendo-decrescendo murmur is audible at the RUSB, radiating to carotid arteriesSystolic crescendo-decrescendo murmur is audible at the RUSB, radiating to carotid arteries •Pressure differentials between LV & aorta, obtained at catheterization, pathognomonic for ASPressure differentials between LV & aorta, obtained at catheterization, pathognomonic for AS TransvalvularTransvalvular gradientgradient
- 28. ABB MD FACCABBMD FACC©© Critical Aortic Stenosis: Transvalvular GradientCritical Aortic Stenosis: Transvalvular Gradient LALA LVLV AortaAorta ApexApex ESES MSMMSMSS11 SS22 LVEDPLVEDP TransvalvularTransvalvular gradientgradient TransvalvularTransvalvular gradientgradient
- 29. ABB MD FACCABBMD FACC©© Critical Aortic Stenosis: Transvalvular GradientCritical Aortic Stenosis: Transvalvular Gradient
- 30. ABB MD FACCABBMD FACC©© Bicuspid Aortic Valve With Aortic RegurgitationBicuspid Aortic Valve With Aortic Regurgitation (Tricuspid) rheumatic or(Tricuspid) rheumatic or degenerative aortic valvedegenerative aortic valve Congenital bicuspidCongenital bicuspid aortic valveaortic valve
- 31. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Valve Lesions & Hemodynamics (AR)Valve Lesions & Hemodynamics (AR) Normal pressuresNormal pressures Aortic regurgitationAortic regurgitation
- 32. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Aortic Regurgitation HemodynamicsAortic Regurgitation Hemodynamics Aortic regurgitation on MRAAortic regurgitation on MRA Upsloping LVUpsloping LV diastolic pressurediastolic pressure Wide pulse pressureWide pulse pressure
- 33. ABB MD FACCABBMD FACC©© Acute Versus Chronic Aortic RegurgitationAcute Versus Chronic Aortic Regurgitation
- 34. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Mitral RegurgitationMitral Regurgitation
- 35. ABB MD FACCABBMD FACC©© Overall Causes of Mitral RegurgitationOverall Causes of Mitral Regurgitation
- 36. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Causes of Mitral InsufficiencyCauses of Mitral Insufficiency
- 37. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Causes of Severe Mitral RegurgitationCauses of Severe Mitral Regurgitation MV leaflet perforationMV leaflet perforation Papillary muscle infarctPapillary muscle infarct mitral annular calcificationmitral annular calcificationBillowing mitral leaflets (MVP)Billowing mitral leaflets (MVP)
- 38. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Mitral Stenosis & RegurgitationMitral Stenosis & Regurgitation
- 39. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Myxomatous MVP: Forms of Mitral RegurgitationMyxomatous MVP: Forms of Mitral Regurgitation
- 40. ABB MD FACCABBMD FACC©© Valve Lesions & Hemodynamics (MR)Valve Lesions & Hemodynamics (MR) Normal pressuresNormal pressures Mitral regurgitationMitral regurgitation
- 41. ABB MD FACCABBMD FACC©© Acute Versus Chronic Mitral RegurgitationAcute Versus Chronic Mitral Regurgitation
- 42. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Carotid Pulse & Cardiac AuscultationCarotid Pulse & Cardiac Auscultation in Critical AS versus Acute MRin Critical AS versus Acute MR 1) Critical aortic stenosis1) Critical aortic stenosis 2) Acute mitral regurgitation2) Acute mitral regurgitation AS or Acute MR??AS or Acute MR??
- 43. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Summary of Systolic MurmursSummary of Systolic Murmurs
- 44. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Mitral StenosisMitral Stenosis AorticAortic pressurepressure LVLV pressurepressure LVDMLVDM pressurepressure Mitral stenosisMitral stenosis
- 45. ABB MD FACCABBMD FACC©© Mitral StenosisMitral Stenosis
- 46. ABB MD FACCABBMD FACC©© Critical Mitral StenosisCritical Mitral Stenosis Mitral stenosis chest X-ray: P-A viewMitral stenosis chest X-ray: P-A view Mitral stenosis:Mitral stenosis: superior viewsuperior view RheumaticRheumatic heart diseaseheart disease with mitralwith mitral stenosisstenosis
- 47. ABB MD FACCABBMD FACC©© Severe Longstanding Mitral StenosisSevere Longstanding Mitral Stenosis Mitral stenosis in the parasternal long axisMitral stenosis in the parasternal long axis Mitral stenosis in the apical 4 chamber viewMitral stenosis in the apical 4 chamber view Normal mitral in the parasternal long axisNormal mitral in the parasternal long axis Normal mitral in the apical 4 chamber viewNormal mitral in the apical 4 chamber view
- 48. ABB MD FACCABBMD FACC©© Valve Lesions & Hemodynamics (Mitral Stenosis)Valve Lesions & Hemodynamics (Mitral Stenosis) Normal pressuresNormal pressures Mitral stenosisMitral stenosis
- 49. ABB MD FACCABBMD FACC©© Normal MV Function vs. Mitral StenosisNormal MV Function vs. Mitral Stenosis
- 50. ABB MD FACCABBMD FACC©© Mitral StenosisMitral Stenosis Pre balloonPre balloon angioplastyangioplasty Post balloonPost balloon angioplastyangioplasty
- 51. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Summary of Diastolic MurmursSummary of Diastolic Murmurs
- 52. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Percutaneous Aortic Valve ImplantationPercutaneous Aortic Valve Implantation
- 53. ABB MD FACCABBMD FACC©© ABB MD FACCABB MD FACC©© Percutaneous Aortic Valve ImplantationPercutaneous Aortic Valve Implantation
- 54. ABB MD FACCABBMD FACC©© Mitral regurgitationMitral regurgitation Mitral stenosisMitral stenosis Aortic regurgitationAortic regurgitation Aortic StenosisAortic Stenosis
Editor's Notes
- #6 Generally in the body, blood flow is laminar. However, under conditions of high flow, particularly in the ascending aorta, laminar flow can be disrupted and become turbulent. When this occurs, blood does not flow linearly and smoothly in adjacent layers, but instead the flow can be described as being chaotic. Turbulent flow also occurs in large arteries at branch points, in diseased and narrowed (stenotic) arteries (see figure below), and across stenotic heart valves. Turbulence increases the energy required to drive blood flow because turbulence increases the loss of energy in the form of friction, which generates heat. When plotting a pressure-flow relationship (see figure to right), turbulence increases the perfusion pressure required to drive a given flow. Alternatively, at a given perfusion pressure, turbulence leads to a decrease in flow.
- #9 Generally in the body, blood flow is laminar. However, under conditions of high flow, particularly in the ascending aorta, laminar flow can be disrupted and become turbulent. When this occurs, blood does not flow linearly and smoothly in adjacent layers, but instead the flow can be described as being chaotic. Turbulent flow also occurs in large arteries at branch points, in diseased and narrowed (stenotic) arteries (see figure below), and across stenotic heart valves. Turbulence increases the energy required to drive blood flow because turbulence increases the loss of energy in the form of friction, which generates heat. When plotting a pressure-flow relationship (see figure to right), turbulence increases the perfusion pressure required to drive a given flow. Alternatively, at a given perfusion pressure, turbulence leads to a decrease in flow.
- #26 Aortic stenosis (AS) The classic murmur of aortic stenosis is a high pitched, crescendo-decrescendo ("diamond shaped"), midsystolic murmur located at the aortic listening post and radiating toward the neck. The radiation of the aortic stenosis murmur is often mistaken for a carotid bruit. The aortic stenosis murmur is also well known to radiate to the cardiac apex on occasion, making it difficult to distinguish if mitral regurgitation is also present. This radiation of the aortic stenosis murmur to the apex is known as "Gallavardin dissociation". It requires dynamic auscultation or echocardiography to determine if coexisting mitral regurgitation is the cause of the apical murmur in a patient with aortic stenosis. The intensity of the murmur of aortic stenosis is not a good indicator as to the severity of disease. As aortic stenosis worsens, the LV begins to fail and the ejection fraction declines to the point where sufficient force to create turbulent flow is no longer produced, resulting in a decrease in the intensity of the murmur. While the intensity of the murmur may not be an accurate determinant of the severity of aortic stenosis, the shape of the murmur can be very helpful. As aortic stenosis worsens, it takes longer for blood to eject through the valve, so the peak of the crescendo-decrescendo murmur moves to later in systole. Thus mild aortic stenosis would have an early peaking murmur while the murmur of severe aortic stenosis peaks later in systole. Remember from the heart sounds section that the delay in aortic valve closure can cause a paradoxically split S2 heart sound and as the aortic valve becomes more heavily calcified, the intensity of the S2 heart sound declines. Also, in patients with bicuspid aortic valves, an ejection click may be heard just before the murmur begins.
- #27 Aortic stenosis (AS) The classic murmur of aortic stenosis is a high pitched, crescendo-decrescendo ("diamond shaped"), midsystolic murmur located at the aortic listening post and radiating toward the neck. The radiation of the aortic stenosis murmur is often mistaken for a carotid bruit. The aortic stenosis murmur is also well known to radiate to the cardiac apex on occasion, making it difficult to distinguish if mitral regurgitation is also present. This radiation of the aortic stenosis murmur to the apex is known as "Gallavardin dissociation". It requires dynamic auscultation or echocardiography to determine if coexisting mitral regurgitation is the cause of the apical murmur in a patient with aortic stenosis. The intensity of the murmur of aortic stenosis is not a good indicator as to the severity of disease. As aortic stenosis worsens, the LV begins to fail and the ejection fraction declines to the point where sufficient force to create turbulent flow is no longer produced, resulting in a decrease in the intensity of the murmur. While the intensity of the murmur may not be an accurate determinant of the severity of aortic stenosis, the shape of the murmur can be very helpful. As aortic stenosis worsens, it takes longer for blood to eject through the valve, so the peak of the crescendo-decrescendo murmur moves to later in systole. Thus mild aortic stenosis would have an early peaking murmur while the murmur of severe aortic stenosis peaks later in systole. Remember from the heart sounds section that the delay in aortic valve closure can cause a paradoxically split S2 heart sound and as the aortic valve becomes more heavily calcified, the intensity of the S2 heart sound declines. Also, in patients with bicuspid aortic valves, an ejection click may be heard just before the murmur begins.
- #28 Aortic stenosis (AS) The classic murmur of aortic stenosis is a high pitched, crescendo-decrescendo ("diamond shaped"), midsystolic murmur located at the aortic listening post and radiating toward the neck. The radiation of the aortic stenosis murmur is often mistaken for a carotid bruit. The aortic stenosis murmur is also well known to radiate to the cardiac apex on occasion, making it difficult to distinguish if mitral regurgitation is also present. This radiation of the aortic stenosis murmur to the apex is known as "Gallavardin dissociation". It requires dynamic auscultation or echocardiography to determine if coexisting mitral regurgitation is the cause of the apical murmur in a patient with aortic stenosis. The intensity of the murmur of aortic stenosis is not a good indicator as to the severity of disease. As aortic stenosis worsens, the LV begins to fail and the ejection fraction declines to the point where sufficient force to create turbulent flow is no longer produced, resulting in a decrease in the intensity of the murmur. While the intensity of the murmur may not be an accurate determinant of the severity of aortic stenosis, the shape of the murmur can be very helpful. As aortic stenosis worsens, it takes longer for blood to eject through the valve, so the peak of the crescendo-decrescendo murmur moves to later in systole. Thus mild aortic stenosis would have an early peaking murmur while the murmur of severe aortic stenosis peaks later in systole. Remember from the heart sounds section that the delay in aortic valve closure can cause a paradoxically split S2 heart sound and as the aortic valve becomes more heavily calcified, the intensity of the S2 heart sound declines. Also, in patients with bicuspid aortic valves, an ejection click may be heard just before the murmur begins.
- #53 Valvuloplasty is a cardiac catheterization procedure to treat stenosis in heart valves. It is similar to a balloon angioplasty, except instead of opening an artery, a valvuloplasty stretches open a narrowed heart valve. During the procedure, a deflated balloon catheter is inserted through a blood vessel to the opening of the narrowed heart valve. The balloon is inflated to stretch the valve open. Balloon valvulopasty is used to treat blockage of the mitral valve or of the aortic valve
- #58 Aortic stenosis (AS) The classic murmur of aortic stenosis is a high pitched, crescendo-decrescendo ("diamond shaped"), midsystolic murmur located at the aortic listening post and radiating toward the neck. The radiation of the aortic stenosis murmur is often mistaken for a carotid bruit. The aortic stenosis murmur is also well known to radiate to the cardiac apex on occasion, making it difficult to distinguish if mitral regurgitation is also present. This radiation of the aortic stenosis murmur to the apex is known as "Gallavardin dissociation". It requires dynamic auscultation or echocardiography to determine if coexisting mitral regurgitation is the cause of the apical murmur in a patient with aortic stenosis. The intensity of the murmur of aortic stenosis is not a good indicator as to the severity of disease. As aortic stenosis worsens, the LV begins to fail and the ejection fraction declines to the point where sufficient force to create turbulent flow is no longer produced, resulting in a decrease in the intensity of the murmur. While the intensity of the murmur may not be an accurate determinant of the severity of aortic stenosis, the shape of the murmur can be very helpful. As aortic stenosis worsens, it takes longer for blood to eject through the valve, so the peak of the crescendo-decrescendo murmur moves to later in systole. Thus mild aortic stenosis would have an early peaking murmur while the murmur of severe aortic stenosis peaks later in systole. Remember from the heart sounds section that the delay in aortic valve closure can cause a paradoxically split S2 heart sound and as the aortic valve becomes more heavily calcified, the intensity of the S2 heart sound declines. Also, in patients with bicuspid aortic valves, an ejection click may be heard just before the murmur begins.