heart murmurs & valvular heart disease victor politi, m.d., facp medical director, svcmc, school...

Heart Murmurs & Valvular Heart Disease

Victor Politi, M.D., FACPMedical Director, SVCMC, School of Allied Health Professions, Physician Assistant Program

What is a Heart Murmur?

A sound produced as blood flows through the chambers and large blood vessels of the heart during the cardiac cycle of contraction and relaxation.

The heart beat normally makes two sounds: the first is Lub and the second is Dub,

these two sounds follow each other (Lub Dub) and are not separated by any extra sounds.


A heart murmur will be heard as a swishing or a whistling sound in addition to the normal Lub-Dub sound.

The moving blood sounds like running water in a garden hose.


A heart murmur is not a diagnosis or disease, it is a sign to alert our attention to check if there is anything wrong.

Heart murmurs come in different sounds which may help indicate whether the murmur is normal or abnormal.


Some murmurs are benign or harmless and are more of a finding than a condition.

A benign murmur is not associated with any significant underlying abnormality of the heart or its vessels.


Many young people can have benign/innocent flow murmurs and still have normal cardiac structure and function.


What causes a heart murmur?

Innocent/Benign Murmur Causes: Anemia Fever Venous Hum

a common innocent murmur heard during childhood. This murmur is heard as a soft humming sound at the base of the neck just above the collarbone. It results from the normal blood flow in the large neck veins (jugular veins).

Innocent/benign Causes: Venous Hum

Light compression of the neck vein will make the murmur transiently disappear, or the murmur will sound louder when turning the child's head to one side or another.

These simple maneuvers help differentiate a Venous Hum from the murmurs resulting from heart disease.

Innocent/benign Causes: Still’s Murmur

This heart murmur is named after the doctor who described it.

It is heard most frequently in active, healthy 3 to 7-year old children.

The murmur represents the normal sound of blood gushing out into the aorta during heart contraction.

It has a musical tone to it and thus is frequently described as "musical murmur"; it usually sounds softer during sitting and may sound very loud during fever, anxiety, or exercise.

Still’s Murmur

Pathologic Murmur

A pathologic heart murmur is one associated with a structural or functional abnormality of the heart.

Pathologic Murmurs

Narrow Valve- stenosis Valve insufficiency/regurgitationSeptal defects- Hole in the Heart

Valve insufficiency/regurgitation

As the heart valve closes some blood leaks back making a blowing sound.

A leaking valve is called insufficient or regurgitating.

Its importance depends on how much blood is leaking, what valve is involved, and how long it has been going on.

Septal defects – hole in heart

If the pressure in the heart chambers is not the same, the blood will flow from the high to the low-pressure chamber, producing a murmur sounding like a waterfall.

If the hole is small, it will make a very loud sound.

If the hole is large it may make a faint murmur that may go unnoticed for some time; therefore a faint murmur may sometimes indicate a serious problem.

If it is between the upper cardiac chambers, it is called Atrial Septal Defect (ASD), and is called Ventricular Septal Defect (VSD) if it is between the lower cardiac chambers.

The importance of septal defects depends on their size and site.

Septal defects – hole in heart

Most murmurs are produced as blood flows past the cardiac valves, which separate the chambers of the heart, or through the valves that lead to the great vessels of the lungs and the systemic circulation.

Mechanisms of Heart Murmurs


They are usually caused by one of the following mechanisms: Flow across partial obstruction (e.g. aortic

stenosis) Flow across valvular or intravascular

irregularity w/o obstruction (e.g. bicuspid aortic valve w/o true stenosis)

Increased flow through normal structures (e.g. aortic systolic murmur associated w/anemia)

Flow into dilated chamber (e.g. aortic systolic murmur associated w/aneurysmal dilatation of the ascending aorta)

Backward or regurgitant flow across an incompetent valve or defect (e.g. mitral regurgitation)

Shunting of blood out of a high pressure chamber or artery through abnormal passage (e.g. ventricular septal defect)


Midsystolic Ejection Murmurs

Most common type of murmurMay be:

1. Organic (i.e. secondary to structural cardiovascular

abnormality)

2. Functional (i.e. secondary to a physiologic alteration w/or w/o

heart dx)

3. Innocent(i.e. not associated with any functional or structural

abnormality)

Organic causes include: Aortic stenosis Pulmonoic stenosis

Midsystolic Ejection Murmurs

Pansystolic Regurgitant Murmurs

Heard when blood flows from a chamber of high pressure to one of lower pressure through a valve or other structure that should be closed.

Regurgitation (incompetence or insufficiency) means there is a leak!

The murmur begins immediately with the 1st heart sound and continues up to the 2nd heart sound.

Causes include: Mitral regurgitation LV LA Tricuspid regurgitation RV RA Ventricular septal defect LV RV

Pansystolic Regurgitant Murmurs

Diastolic Murmurs

Unlike systolic murmurs, diastolic murmurs are almost always indicative of heart disease.

Two general types may be distinguished:

The diastolic rumble originating in atrioventricular valves

The early diastolic murmurs of semilunar valve incompetence

Diastolic rumbling murmurs are caused by: Flow across distorted or stenotic mitral

or tricuspid valves Increased blood flow across normal

mitral or tricuspid valves

Diastolic Murmurs

Because these valves open only after the aortic and pulmonic valves close, a short period of silence separates S2 from the beginning of diastolic rumbles.

These murmurs are low in pitch, rumbling in quality, and heard best with the bell of the stethoscope in light skin contact.

Diastolic Murmurs

Semilunar valve incompetence may result either from valvular deformity or from dilatation of the valvular ring.

In either case blood regurgitates from the great vessel back into the ventricle.

Diastolic Murmurs

Murmurs of aortic regurgitation, together with most murmurs of pulmonic regurgitation, start immediately after the second sound and then diminish in intensity

In contrast to the rumbling atrioventricular valve murmurs, they are high pitched and blowing and best heard with the diaphragm pressed firmly on the chest.

Diastolic Murmurs

The most common examples of these two types of diastolic murmurs are:

Mitral stenosis Aortic regurgitation

Diastolic Murmurs

Points to Remember !

If the flow is excessive or turbulent, a murmur may be manifest.

Blood flowing through a tight valve will produce a murmur.

Blood that is leaking back across an improperly sealing valve also can cause a murmur.

Occasionally, abnormal communications (holes) between chambers of the heart can result in the presence of a murmur.

Diagnosing a Murmur

Diagnosing a heart murmur begins with auscultation of the heart.

The location, quality, pitch and variation in the sound are all important clues to whether the murmur is benign or pathologic.

Murmur Evaluation

One of the most useful tests in evaluating a murmur is an echocardiogram.

Other tests – EKG Chest x-ray

Valvular Heart Disease

90% of valvular disease is chronic, with decades between the onset of the structural abnormality and symptoms

The four heart valves prevent retrograde flow of blood during the cardiac cycle, allowing efficient ejection of blood with each contraction of the cardiac chambers

The mitral valve has two cusps, while the other three heart valves normally have three cusps

The right and left papillary muscles promote effective closure of the tricuspid and mitral valves, respectively.

Valvular Heart Disease

Mitral StenosisMitral RegurgitationAortic StenosisAortic RegurgitationTricuspid StenosisTricuspid Regurgitation

Mitral Stenosis

Mitral Stenosis- Pathophysiology

Despite its declining frequency, rheumatic heart disease is still the most common cause of mitral valve stenosis

Due to progressive dilation of the atria, many patients with mitral stenosis will go on to develop atrial fibrillation

Mitral Stenosis

Normal mitral valve 4-6cm2

When the valve narrows <1.5cm2, left atrial pressure must rise to maintain normal flow across the valve and a normal cardiac output

This results in a pressure difference between the left atrium and the left ventricle during diastole

Mitral Stenosis

In mild cases of mitral stenosis, the patient may be asymptomatic and cardiac output and left atrial pressure may be normal

In moderate cases (valve area < 1.5cm2) as left atrial pressure rises - dyspnea and fatigue appear

Mitral Stenosis

With severe stenosis, pulmonary venous congestion at rest and reduced cardiac output occur resulting in dyspnea, fatigue, and right sided heart failure

Mitral Stenosis - Clinical Findings

Dyspnea In 80% of cases, most common presenting

symptom Paroxysmal nocturnal dyspnea

hemoptysis 2nd most common symptom

OrthopneaSymptoms often precipitated by onset of

pregnancy or atrial fibrillation

Mitral Stenosis - Clinical Findings

Murmur duration varies - severity of stenosis &

heart rate middiastolic rumble, crescendos into S2

Heart Sounds long snapping S1

apical impulse is small and tapping due to underfilled left ventricle

Mitral Stenosis - Murmur

The pressure gradient and the length of the diastolic murmur reflect the severity of mitral stenosis

Mitral StenosisDiagnostic Studies

Echocardiography reveals thickened valve that opens poorly, closes

slowly rather than moving in opposite directions, the

anterior and posterior leaflets are fixed, moving together

rule out atrial myxoma (clinical presentation similar to mitral stenosis)

left atrial size can be accurately measuredincreased size - increased risk of atrial fibrillation or

systemic emboli

Mitral Stenosis - Diagnostic Studies

ECG may show notched or diphasic P waves and

right axis deviationX-ray

early finding- straightening of left heart border (left atrial enlargement)

subsequent findings - pulmonary congestion, redistribution of flow to upper lung fields, Kerley B lines, along with an increase in vascular markings

Kerley B lines are short, horizontal linear radiopacities at the periphery of the lung that represent thickened, interlobular septa

Mitral Stenosis -Treatment

Warfarin anticoagulation - after A-Fib Surgery - indications

uncontrolled pulmonary edema limiting dyspnea & intermittent pulmonary

edema pulmonary HTN w/right ventricular

hypertrophy or hemoptysis limitation of activity despite ventricular rate

control/medical therapy recurrent systemic embolic despite

anticoagulation w/moderate-severe stenosis

Mitral StenosisTreatment

Open mitral commissurotomy patients w/o substantial mitral

regurgitationValve replacement surgery

indicated when combined stenosis and insufficiency are present or when the mitral valve is so distorted and calcified that a satisfactory valvulotomy is impossible

Mitral Stenosis

Prosthetic valves Warfarin anticoagulant therapy required -

usually for at least initial 3 months with bioprosthesis - if atrial fibrillation persists - anticoagulation therapy should continue

possible problemsthrombosisparavalvular leakendocarditisdegenerative changes in tissue valves

Mitral StenosisTreatment

Balloon valvuloplasty effective in patients w/o mitral

regurgitation and in cases where valve calcification is not excessive

Mitral Regurgitation(Mitral Insufficiency)

(Mitral Incompetence)

Mitral Regurgitation

The mitral leaflets do not close normally during left ventricular systole, blood is ejected into the left atrium as well as through the aortic valve

this results in increased volume load on the left atria


Mitral Regurgitation leads to left atrial enlargement - subsequently resulting in atrial fibrillation


Case presentation varies depending upon the speed with which the condition develops

In acute cases, left atrial pressure elevates abruptly can result in pulmonary edema if severe


Acute cases Typically, patient presents with dyspnea,

tachycardia, and pulmonary edema ECG-may show evidence of acute inferior wall

infarction (more common than anterior wall) absent to minor calcification of mitral valve no stenosis, little left ventricle dilation X-ray-minimally enlarged left atrium,

pulmonary edema - from papillary muscle rupture


In chronic cases, the left atrium dilates, left atrial pressure rises little, even with large regurgitant flow slowly progressive- years to decades exertional dyspnea (1st symptom), and fatigue that

progress gradually over years pressure in the pulmonary veins show a transient rise

during exercise ECG-may demonstrate LVH x-ray-left ventricular/atrial enlargement in proportion to

severity of regurgitant volume


Intermittent cases typically present with acute episodes of

respiratory distress due to pulmonary edema

can be asymptomatic between attacks


Many causes - rheumatic disease myxomatous degeneration (mitral valve

prolapse) connective tissue disease (Marfan's

syndrome) infective endocarditis cardiac tumors (myxoma) - rare cause


Nonrheumatic mitral regurgitation may develop suddenly after MI,valve perforation in infective endocarditis, or ruptured chordae tendineae in MVP

Inferior MI due to right coronary occlusion is the most common cause of ischemic mitral valve incompetence


Rheumatic heart disease is the most common cause of chronic mitral incompetence


Appetite suppressant drugs (fenfluramine and phentermine, or dexfenfluramine) have been associated with cardiac valve incompetence


Murmur Acute; harsh apical systolic murmur,

begins with S1, may end before S2

Heart Sounds S1 and S2 are heard

Mitral Regurgitation - Diagnostic Studies

Echocardiography

TEE

Nuclear Medicine/MRI

Cardiac Cath

MVP

Click-murmur syndromeEtiology unknown - possibly congenitalUsually asymptomatic May be associated with

nonspecific chest pain dyspnea fatigue palpitations

MVP

Characteristic midsystolic click may be multiple, often followed by late

systolic murmur accentuated in standing position

Most commonly affects women 10% of cases - healthy young women many thin some with minor chest wall deformities

MVP

Usually no sequelae if only midsystolic click present

significant mitral regurgitation may develop in cases with late or pansystolic murmur (due to rupture of chordae tendineae)

MVP

Need for valve replacement increases with age men more than women require surgery 2% of patients over age 60 with

significant regurgitation require surgeryTo reduce risk of endocarditis -

antibiotic prophylaxis prior to dental work or surgery

MVP

Aggressive management necessary in cases of symptomatic ventricular tachycardia

Diagnosis primarily clinical - can be confirmed by echocardiogram

MVP

With MVP there is an increased incidence of - sudden death dysrhythmias TIA for persons under age 45

MVP

In cases of MVP w/o mitral regurgitation at rest, exercise provokes mitral regurgitation in 32% of patients

this is a predictor for a high risk of morbid events

Mitral regurgitation due to papillary muscle dysfunction/MI

Mitral regurgitation may subside as left ventricular dilatation diminishes or the infarction heals

Transient (sometimes severe) regurgitation may occur after an MI

In cases of persistent severe regurgitation, poor prognosis with or w/o surgery

Secondary Mitral Regurgitation

Papillary muscle dysfunction or dilation of the mitral annulus in patients with dilated cardiomyopathy of any origin

Valve replacement generally contraindicated due to poor risk:benefit ratio

However, valve replacement in cases where the Left EF >30% have shown good result in some studies

Aortic Stenosis

Aortic Stenosis

Blood flow into the aorta is obstructed, producing progressive LVH and low cardiac output

Most commonly, this is caused by progressive valvular calcification In younger patients with congenital

bicuspid valve In the elderly with normal three-cusp

valves

Aortic Stenosis

In the elderly the aortic valve becomes increasingly sclerotic and eventually stenotic

Degenerative valve disease is three -four times more frequent in men than women

More common in smokers and hypertensives

Aortic Stenosis

Congenital heart disease - most common cause

Rheumatic heart disease - second most common cause

degenerative heart disease (calcific aortic stenosis) 3rd most common cause overall Most common cause > age 70

Aortic Stenosis

Treatment surgery is indicated in all symptomatic

patients exceptions -

declining left ventricular functionvery severe left ventricular hypertrophyvery high gradientsseverely reduced valve areas

Aortic Stenosis

Anticoagulation with warfarin is required for mechanical prostheses but not essential with bioprosthesis

bioprosthetic valves undergo degenerative changes and usually require replacement with 7-10 years - newer ones may be more resilient

Aortic Stenosis

Ross procedure switching the patient’s pulmonary valve

to the aortic position, placing a bioprosthesis in the pulmonary position

(bioprosthesis do not deteriorate as fast on the right side of the heart)

This procedure has produced excellent results without anticoagulation

Aortic Stenosis

Percutaneous balloon valvuloplasty short term reduction in severity restenosis recurs rapidly in most adults

with calcified valves used on poor candidates for surgery or

to stabilize high risk patients prior to surgery

Aortic Stenosis

Classic triad of symptoms dyspnea chest pain syncope

Aortic Stenosis

Dyspnea is usually the first symptom, followed by paroxysmal nocturnal dyspnea, syncope on exertion, angina, and MI

Aortic Stenosis

Sudden death, usually from a dysrhythmia, occurs in 25% of cases

x-ray- early on - normal, eventually LVH and findings of CHF are evident if the valve is not replaced

ECG-demonstrates criteria for LVH, left or right bundle branch block is also present in 10% of cases

Aortic Stenosis

Murmur - harsh systolic ejection murmur

Heart sounds paradoxic splitting of S2, S3, and S4 may

be present; pulse of small amplitude; pulse has a slow rise and sustained peak

Aortic Regurgitation(Chronic Regurgitation)(Aortic Incompetence)

Aortic Regurgitation

20% of cases acute in natureInfective endocarditis - accounts for

majority of casesaortic dissection at the aortic root

causes the remainder of cases


In acute cases, sudden increase in backflow of blood into the ventricle raises left ventricular end diastolic pressure, which may cause acute heart failure

Rheumatic heart disease and congenital disease cause the majority of chronic cases


In acute disease - dyspnea most common presenting

symptom (50% of cases) many cases have acute pulmonary

edema with pink frothy sputum fever, chills - if endocarditis cause


Dissection of the ascending aorta typically produces a tearing chest pain - may radiate between the shoulders

ECG changes w/aortic dissection - ischemia or findings of acute inferior MI - suggestive of right coronary artery involvement


Chest xray- in acute state demonstrates acute pulmonary edema with less cardiac enlargement than expected


In chronic disease, the ventricle progressively dilates to

accommodate the regurgitant blood volume

Marked peripheral vasodilation


Chronic regurgitation 1/3 of patients have palpitations

associated with a large stroke volume and/or premature ventricular contractions

Frequently, these sensations are noticed in bed


Chronic Regurgitation wide pulse pressure with prominent

ventricular impulse water hammer pulse may be noted

(peripheral pulse that has a quick rise in upstroke followed by peripheral collapse)


Murmur high pitched blowing diastolic murmur

immediately after S2

Heart Sounds S3 may be present; wide pulse pressure


An association between the appetite -suppressant drugs (fenfluramine and phentermine or dexfenfluramine) has also been found for aortic incompetence

Tricuspid Stenosis

Usually rheumatic in originshould be suspected when right

heart failure appears in course of mitral valve disease - marked by hepatomegaly, ascites, and dependent edema

May also occur in carcinoid syndrome

Tricuspid Stenosis

Typical diastolic rumble along lower left sternal border mimics mitral stenosis

in sinus rhythm, a presystolic liver pulsation noted

Echocardiography & dopplerCardiac Cath - diagnositic

Tricuspid Stenosis

Surgical options valvotomy prosthetic valve replacement balloon valvuloplasty (experience

limited) may be initial procedure

Tricuspid Regurgitation

Right ventricle overload - result of left ventricular failure of any cause

occurs in conjunction with right ventricular and inferior MI

IV drug users - tricuspid valve endocarditis and regurgitation common


Other causes carcinoid syndrome lupus erythematosus myxomatous degeneration of the valve

(associated with MVP) Ebstein’s anomaly


Signs/symptoms identical to those of right ventricular

failure In presence mitral valve disease -

early onset right heart failureharsh systolic murmur - lower left sternal

border - (separate from mitral murmur)


Prominent regurgitant systolic v wave in right atrium and jugular venous pulse

regurgitant wave, systolic murmur increased with inspiration

Inspiratory S3 may be present

when secondary to mitral valve disease or other left sided disease my regress when underlying disease corrected


Surgical repair valve repair or valvuloplasty of tricuspid

ring preferred to valve replacement

Questions ??

heart murmurs & valvular heart disease victor politi, m.d., facp medical director, svcmc, school...

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