MEDISIN 2018 | C. Herrera & A. Kosallavat

Physiology | Heart Valves & Sounds| Dr. Rene Manalo October 28, 2014

- 2 AV valves situated between atria and

ventricle - 2 Semilunar valves shaped half moon

2 AV valves

- Tricuspid valve right side - Bicuspid / Mitral valve left side

2 Semilunar valves - Pulmonic valve - Aortic valve

FUNCTION:

- Ensure unidirectional flow; ensure cardiac cycle kept intact, there would be forward flow of blood, no unidirectional flow, circulation subject to abnormalities like regurgitation

- When atrial chambers contract, ventricular chambers should be relaxed.

- Systole / diastole (without specification if atria or ventricle) ventricular event

ANATOMICAL VS. CLINICAL LOCATION OF VALVES CLINICAL

- Doesnt totally jive with anatomical location

VALVE LOCATION Transmits its sound

to:

Pulmonic 2nd left ICS, para sternal line

Aortic 2nd Right ICS, parasternal line

Tricuspid Subxyphoid region (same)

Mitral 5th left ICS, midclavicular line

- Left side of heart pressure adapted, thicker - Right side volume adapted, thinner - * volume overload in left side, it will fail in

minutes to hours (pulmonary edema - severe heart failure)

- * increase in pressure at the right side failure SA node

- Entrypoint at SVC - Connected to AV node throught 3 internodal

tract (facilitiate the speed of impulse transmission)

o Bachmann o Wenckeback

o Thorel AV node

- Junction rhythm - Gives off the bundle of His

2 divisions: o Left Bundle

Left anterior Left posterior fascicles

o Right Bundle *lateral leads physiologic q wave: septal depolarization SA node atrial depolarization *0.1 sec PR interval Bundle of his left first then right (R wave)

AUSCULTATION 2 types:

- Direct auscultation: ears to patients chest - Indirect auscultation: French physician, Rene

Laennec (through the use of paper) - Cardiac stethoscope for low frequency sound

Parts: - Earpiece - Rubber tubing (25in length) - Chest piece

o Bell conical part, attuned to low pitch sound, apply very lightly, much pressure will deplete the sound, stretches the skin creating a diaphragm

o Diaphragm for high pitch sound, apply pressure, double diaphragm effect

HEART SOUNDS

1. Transients a. S1, S2, S3, S4 b. Clicks, snaps

2. Murmus a. Turbulence b. Vortex shedding

Clicks

- Midsystolic click: Lub-click-Dub o MITRAL VALVE PROLAPSE (BARLOWS

SYNDROME) o Female, tall, slim, straight back (8F:1M) o Tx: reassurance, antibiotics, o Mitral endocarditis

Opening Snap - MITRAL STENOSIS valvular condition from

RHD - Sound produced when the mitral valve open.

MEDISIN 2018 | C. Herrera & A. Kosallavat

NORMAL HEART SOUNDS **Normal Heart sounds are produced on CLOSURE of VALVES

S1 closure of AV valves S2 closure of SL valves S3 phase of rapid ventricular filling S4 atrial contraction; ATRIAL KICK S1

- LUBB - Longer - Lower pitch - Louder at the apex

S2 - DUP - Shorter - Higher pitch - Softer at the apex

**Insert drawing. **ventricular diastole

- Coronary artery fills up Systolic time is preserved. Diastolic time shortened in tachycardia S1 and S2 determines the CO At the base, the same except intensity of sound

- S1 becomes softer, S2 becomes louder

CONTINUATION: OCTOBER 29, 2014 S1- increases its intensity when the heart rate is fast (tachycardia)

- Abnormally increased: MITRAL STENOSIS - Decrease intensity is normal when HR is slow - Abnormally decreased: MYODCARDIAL

ISCHEMIA, CHF S2 S1 P2 S1 P2 A2 A2 Due to inspiration there is increase venous return in the right side, causes the splitting Widened S2 splitting

- present on expiration and more pronounced (further delay) during inspiration

- due to RBBB QRS will look like M Paradoxical S2 splitting

- splitting on expiration - becomes single on inspiration, the increase in

venous return

- pulmonic component appearing first, followed by aortic component

- due to LBBB Fixed S2 splitting

- in both inspiration & expiration will have S2 splitting

- due to ASD (Atrial Septal Defect) S3

- normally old upto about 18y/o - most intense time during (preschool) - presence in adult, denotes heart failure (earliest

sign) - VENTRICULAR GALLOP (abnormal)

protodiastolic gallop (early in diastole): Heart Failure

- KENTUCKY - S2 is near S3

S4

- Should not be heard by the age 18 - ATRIAL GALLOP / PRESYSTOLIC GALLOP - S4 near S1; distorts the quality of S1 LUBBA -

DUP - Contraction of the atrial chamber - TENNESSEE

SUMMATION GALLOP

- All gallops are present LUBBA DUPPA - MISSISSIPPI

Left atrium left ventricle SV delivered, the aortic valve closes; not completely drained, then end systole, Mitral valve silently opens by pressure gradient the pressure is transferred. LOST! LVEDP, atrial chamber contracts, push the residual volume (S4). MURMURS 2 mechanisms:

1. Turbulence -Vessel, laminar flow, disruption to normal flow -HEMIC MURMURS (temporary), in cases of mod to severe anemia, pregnancy, thyrotoxicosis, AV fistulas (abnormal connection between artery and vein)

2. Vortex shedding -EDDYING

MEDISIN 2018 | C. Herrera & A. Kosallavat

**Systolic murmurs, may or may not be abnormal diastolic murmurs are ALWAYS ABNORMAL STILLs MURMUR

- Systolic murmurs, best heard in pulmonic area - Musical quality and vibratory quality - Usually heard in children 4-5 y/o

**most murmur occur mostly in valvular defect and.., the intensity of murmurs inversely prop to the defect (the louder the murmur, the smaller the defect) Strep thoat, stimulates the immune system, the reaction is delayed, produced streptolysin O, destroys the strep.

- Rheumatic arthritis - RHD: Carditis

The valve becomes deform, the initial lesion is incompetent, there is insufficiency, causes regurgitation Once it heals, produced stenosis (FISH MOUTH lesion)

- Systolic Semilunar valve Stenosis - Systolic AV valve Regurgitation - Diastolic Semilunar valve regurgitation - Diastolic AV valve Stenosis - Systole and Diastole (machinery murmur) :

GIBSONs MURMUR Patent ductus arteriosus