Murmur Aortic stenosis Aortic Regurg Mitral Stenosis Mitral Regurg O/E Slow-rising, low vol pulse Narrow pulse pressure Undisplaced, sustained (heaving) apex Ao thrill ESM to carotids Soft S2
Collapsing, large vol pulse Wide pulse pressure Displaced, hyperkinetic apex Ao thrill Early diastolic murmur (LLSE) (MDM aka Austin Flint)) Mid-systolic flow Quincke's (nail bed)
Traube's (pistol-shot femoral) Duroziez (diastolic murmur prox to fem arty compression) Corrigan's (neck) De Musset's (nodding) Muller (uvula)
Malar flush Small vol pulse +/-AF Undisplaced, tapping apex RV heave Loud S1 (mobile valve only) OS (after S2 mobile valve only) Mid-diastolic murmur (apex)
Pre-systolic accentuation (if in SR) Small vol pulse +/-AF Displaced thrusting apex Apex thrill RV heave Soft S1 Split S2 (early closure of AoV) Loud P2 (PHT) PSM " axilla S3
Severity Absent/soft A2 Delayed A2 Delayed ESM Narrow pulse pressure Slow-rising pulse Thrill/heave LVF S4 Loud, short EDM Soft S2 S3 Wide pulse pressure LVF Austin Flint Hill's sign (SBP legs > arms) Longer MDM OS nearer A2 PHT Displaced apex (? size LV) Signs of LVF
Complications LVF IE Conduction dis PHT IE Pulmonary oedema CVA (thromboembolic) Haemoptysis/hoarseness IE Pulmonary oedema
Causes Congenital Degenerative (calcified) Bicuspid Rheumatic Assoc ?: Coarctation Bicuspid AV Angiodysplasia MAHA Congen Acute Chronic Valv IE RhF CTD (inc RA) Ao root Trauma Dissect (A) Dilatation (HTN, marfan's) Aortitis (syphilis, ank spond) Acquired: RhF (? f) Rarely [Congen SLE Lt atrial myxoma RA Carcinoid] Congen (assoc ? secundum ASD) Acute: IE Acute MI Chronic: IHD (functional) RhF CTD MVP Valvotomy Amyloid HCM
ECG LVH, LBBB, LAD LVH, TWI P-mitrale, AF, RVH P-mitrale, AF, LVH
CXR Normal +/- calcified valve Cardiomeg, wide mediastinum Large LA, calcified valve Cardiomeg, pulm oedema
Echo Valve area <0.5 cm2 LVESD >55mm Valve <1cm2/m2 LVEF <55%
Mx Asymptomatic: None, unless gradient >50mmHg or worsening ECG (6/12 review, ppx Abx) Symptoms: ARV +/-CABG (operate prior to LV dysfunction) B-blockers (increase ejection time) Acute: AVR Chronic: Sx (prior to LV dysfunction) Or, when pulse pressure >100, ECG changes & LV enlarged on CXR (65% @ 3 yrs) Medical: Warfarin, Digoxin (rate control crucial), diuretics (reduced preload), ppx Abx Surgery: Valvuloplasty (pliable non-calcified valve ? minimal regurg & no Lt atrial thrombus) Valvotomy (open/closed) MVR Medical: Diuretics, ACE, Warfarin, ppx Abx Surgery: MV repair (ideally) or MVR (when symptomatic, prior to LV dilatation)
??dx VSD HOCM PS MR Flow murmur Mixed AoV Disease (AR/AS) Pulse: collapsing/slow-rising Apex: thrusting/heaving Thrill: absent/present SBP: high/low Pulse pressure: wide/narrow Austin Flint Carey-Coombs (RhF) Lt atrial myxoma TR VSD AS
Anything else? Listen for MS as tend to reduce signs of each other Mixed MV Disease (MR/MS) Pulse: sharp, short/small vol Apex: thrusting/tapping S1: soft/loud S3: present/absent Malar flush: MS, SLE, acne rosacea, dermatomyositis, carcinoid, erisipelas
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Cardiology Valves Summary
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