Systolic

Aortic Stenosis
Calcific valvular disease
(elderly)-50%
30-40% Congenital aortic
valve stenosis (males ),
10% RHD,

Pulmonary Stenosis
Congenital (rubella etc)

Associate
d
condition

-L.V.H
-Angina
-Angiodysplasia

-RVH
-TOF!!!

Symptoms

- exercise induced
syncope

- RHF
- mild (asymptomatic)

Cause

Face
Pulse
JVP
Palpation

Auscultat

- slow rising
pulse(anacrotic)
-heaving,apex x displaced
-double impulse (d/t S4/
atrial contraction kick )
Systolic thrill @ aortic
region
-cresendo-decrescendo/

Mitral Regurgitation
RHD (50%), mitral valve prolapse,
I.E. (sub-acute), IHD, Hypertensive HD,
SLE, Marfans syndrome, degeneration of
valves, rupture of chordae tendinae, drugs
(cabergolin)
MITRAL
M-MVP
I-IHD
T-Thyrotoxicosis
R-RHD
A-Autoimmune (SLE,RA)- IE
L-Large heart (dilated cardiomyopathy)
-LAH & LVH

- reduced CO (lethargy, SOB

- CCF
- palpitation (AF)
AF

- a wave present
- a/w thrill (often) @
L. 2nd i/c space
- R. ventricular heave

- Thrusting,forceful, laterally displaced

apex beat
-systolic thrill (severe)

- harsh, midsystolic

- Soft S1

Tricuspid Regurgitation
Functional TR (when RV dilates cor
pulmonale-COPD, M.I., Pul. HPT)
Organic TR ( RHD, I.E., carcinoid
syndrome, Ebstein anomaly)

- atrial & systemic venous pressure

- RHF
- Palpable pulsatile liver in systolic,
Respi: COPD,bronchiectasis
- RHF, Orthopnea, PND, leg swelling,
ascites
Jaundice
- AF (common)
- raise, giant v wave
Left parasternal heave

-blowing PSM best heard on

Other
signs
CXR

ECG

Echo

Treatment

ejection systolic murmur ,

best heard @
aortic(RUSE), radiates to
carotid & accentuate
during expiration
-S4
-soft S2 with slpit
Systolic click
Reduce in valsava (diff
from HOCM)

ejection murmur, best

on inspiration @ L. 2nd
i/c space
- P4 heard
Wide split S2 (ASD)

-PSM @ mitral, radiate to axilla

-expiration
- S3 (CHF)

Narrow pulse pres

- cardiomegaly
-prominent, dilated
asending aorta
-calcification aortic valve
- LVH &LBBB
- ST & T in I, AVL, V5
& V6 (in severe)
- may have ventricular
arrthmias
- thickened, calcified,
immobile, aortic valve
cusps
LVH
-asymtomatic (f/up to
assess sym & echo, a/b

inspiration @ L. lower S.E.

Leg edema
IVDU- needle track @cubital fossa
- prominent pul. artery
d/t post stenotic
dilatation

- L. atrial & ventricle enlargement

- cardiothoracic ratio
-valve calcification

- RA & RV hypertrophy

- bifid p wave p mitrale (LAH)

- tall R @ lead 1 & V6 (LVH)
- deep S @ V1 & V2
*SV1 + RV5/RV6 > 35mm LVH
- dilated LA & LV
- chordal/papillae ms rupture
*not definite in DDx

RV &RA enlarge

- Mild (x symp) conservative ( serial echo,

I.E. prophylaxis

Treat U/L (COPD, IE, RHD)

prophiaxis-amoxicilin for
IE
Surgery

Diastolic

- valvotomy (young)
- Symptomatic ( aortic
valve replacement)<0.8cm2
-percutaneous valve
replacement (balloon
expandable valve for
surgically unfit pt)
Galavardin
phenomenon=high fre
ESM radiate to apex

CCF: acute:nitrates, chronic:diuretic

- in pt awaiting/ not suitable for op
(ACEi,diuretics, anti-coagulants)
- pulmonary valvotomy

- mitral valve repair/replacement (evidence

of progressive cardiac enlargement, not
done in advanced disease)
-emergency mitral valve replacement ( in
chordal/papillary ms rupture, I.E.)

Valve repair,valvuloplasty, valve

replacement

ASD: ESM @ LUSE +

split P2

- Varient Prolapsing/Billowing mitral

valve (excessive large mitral valve leaflets,
young female, a/w Marfans/ RHD/ IHD/
thyrotoxicosis, have atypical submamimary
stabbing pain, mid systolic click murmur,Bblockers + mitral valve repair)

Austin flint murmur: 3rd-4th rib LLSEpulmonary HT

Aortic Regurgitation
Cause

Pulmonary Regurgitation

Mitral Stenosis

Tricuspid Stenosis

<50: post inflammatory:

RHD, I.E, syphilis, Sero-ve
arthropathy (PAIRS),SLE
>50y/o:aortic root dilatation
Marfan severe HPT,

Acquired lesion

RHD

RHD, Mitral/Aortic valve disease,

carcinoid syndrome (rare dz)

Associate
d
condition

- LVH

- Pul. HPT

- CO
-hepatomegaly (pulsatile) &
splenomegaly, ascites, oedema

Symptoms

- LHF (late)
- pounding heart
- Angina

- none

-L. atrial Hypertrophy->

Pulmonary HT
-R. Ventricular hypertrophy
& Dilatation
Systemic emboli (AF>mural thrombus)
IE
-C.C.F
- atrial fib
- neurological (syst.
Emboli)
- mitral facies
- small vol.
-irregularly irregular ( a. fib
-in severe MS)

Face
Pulse

- bounding/ collapsing
Signs
-Quincke (capillary pulsation at nail
bed)
- De Musset ( head nodding with
each heart beat)-systolic pulsation of
uvula
-Duroziez (diatolic murmur @
femoral art. with distal pressure
applied severe)
- pistol shot femoralis (booming @
femoral art. On each heart beat)

- abdominal pain
-swelling
-Peripheral oedema, dyspnoea

JVP

-Increased ()

Palpation

- Trusting,lateral & downward

displacement of apex beat, forceful

Auscultat
e

- pitched early diastolic murmur

best heard @ RUSE with leaning
forward and breath held in expiration
- a/w ejection systolic (volume
overload & mid- diastoilic @apex
(Austin Flint)

Other
signs

Wide pulse pres (Muellers sign)

Hill sign: popliteal SBP>brachial
SBP 60mmHg
Argyll Robertson pupil (syphilis)
Uveitis( Ankylosing spondylitis)
Fundus: roth spot
High arched palate, Hand length> Ht
& kyphoscoliosis (Marfan)
Splenomegaly (Gerhadts)
- LVH & enlargement
- dilatation of ascending aorta,
calcification in syphilis & valvular
disease
- deep S waves @V1
- tall R @V6 (total>35mm)
- LV dilatation
-Enlarged aortic root
- diastolic mitral valve leaflet

CXR

ECG
Echo

- decrescendo diastolic
murmur

-Tapping apex,not
displaced
- palpable S1
- Parasternal heave
- loud S1
- opening snap, rumbling
mid- diastolic murmur
(best heard with bell @ L.
lateral post.
Eccentuate~expiration
++TR/PR
Bruising (anticoagulant)
Narrow pulse pres

-Prominent a wave
-Increased ()

- rumbling mid- diastolic murmur,

best @ LLSE, louder on inspiration

- small heart, enlarged left

atrium
-pul oedema (ABCD)

- prominent R. atrial bulge

-bifid p wave (p mitrale)

-a.fib
- Evaluate Left ventricle &
atrial size and function
Fish mouth deformity

- peaked tall P waves ( >3mm) in

lead II
-Thickened immobile tricuspid valve

(severe)
Treatment

- treat U/l cause (syphilis/ I.E)

- a/b prophilaxis for post-prosthetic
valves surgery

Surgery

-pul. Art. Pressure

- none

- mild > none

-diuretics
-digoxin(a.fib)
Anticoagulants (prevent
atrial thrombus and
systemic embolization)
Ab (amoxicillin )
prophylaxis

- diuretics, salt restriction

- Aortic valve replacement (earlier

better prognosis)

-Trans-septal balloon
valvotomy
-Closed valvotomy
-Open valvotomy
- Mitral valve replacement

-Tricuspid valve replacement

-Tricuspid valvotomy

- Prosthetic valve children adult

- tissue valves elderly
Austin flint: fluttering of ant mitral
valvecusp- apex

C/I preg if <1cm2!!!

Carey coomb murmur:
thicken mitral valve leafletMDM@ apex
Ortner synd: Lt RLN palsy
dlt enlarged RA

- uncommon
-W>M
- rarely isolated lesion

According to Kumar & Clarks Clinical Medicine, 7th Edition

Heaving-pres overload, forceful, sustain, not displace-2 finger
Thrusting-vol overload, non forceful, not sustain, displaced, 3 fingers
S3 (use bell)- high output inflow to incompliant/ distended ventricle (failure) 1,23

S4- Stiff ventricle 41,2