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Cardiology Valves Summary

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Version Jan 2023

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

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

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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