Valvular Heart Disease

• Asymptomatic 62 y/o male

• Long-standing heart murmur

• 2/6 SEM at base of heart

• PMI and carotid upstroke normal

• S2 splits normally

• ECG, CXR normal

Valvular Heart Disease

• What would you do at this time? – Refer to cardiologist – Order an echocardiogram– Follow without further testing until symptoms

develop

Is the Murmur Significant?

• Is the patient symptomatic?

• Are symptoms consistent with cardiac limitation?

• Is there chamber or cardiac enlargement on CXR or examination?

• Is there LVH or RVH on present ECG?

Clues from the Circulatory System

• Jugular venous pulse• Carotid upstroke:

brisk, delayed or weak?

• Peripheral pulses and pulse pressure

• Apical impulse: displaced, sustained or normal?

• Right ventricular lift• Thrill• Heart rate and rhythm

Innocent Cardiac Murmurs

• Midsystolic (never diastolic)

• A2 heard clearly

• Crescendo-decrescendo

• Variable intensity (grade 1-2/6)

• Does not radiate widely

Useful Maneurvers

• Valsalva: decreased venous return during Phase 2

• Squat-Stand: Decreased venous return like Valsalva

• Sustained Hand Grip: increased SVR, increased cardiac output, increased BP

The Second Heart Sound

• Normal: Single S2 in expiration

• Wide: Right bundle branch block, RV pacing

• Fixed: ASD/common atrium

• Paradoxic: Left bundle branch block

Bedside Diagnosis of Pulmonary Hypertension

• P2 > A2 with P2 heard at LV apex

• Secondary findings of tricuspid insufficiency, elevated CVP, pedal edema

• Appropriate clinical situation: known CHF, severe lung disease, loud heart murmur, cardiac arrhythmia

Most Common Misdiagnosed Systolic Murmurs

• Mild Aortic Stenosis

• Mild Pulmonic Stenosis

• Atrial Septal Defect

• Mitral Valve Prolapse

• Hypertrophic Cardiomyopathy Question: Who warrants SBE prophylaxis?

SBE Prophylaxis-2007 Guidelines

• Prosthetic cardiac valve

• Previous infectious endocarditis

• Complex congenital heart disease

• Cardiac transplantation recipients who develop cardiac valvulopathy

Valvular Heart Disease Mild to Moderate Aortic Stenosis• Yearly history and physical examination

• Focus on symptoms of angina, CHF, near syncope

• Echocardiogram q 3-5 years (peak velocity < 3 M/sec)

Valvular Heart Disease:Moderate to Severe Aortic Stenosis

• Annual history and physical examination

• Angina, CHF or near syncope?

• Echocardiogram yearly

• Peak velocity > 3 M/sec

Pulmonic Stenosis

• Congenital lesion with systolic ejection click

• Systolic ejection murmur at left upper sternal border

• Infraclavicular radiation

• Right ventricular lift

Atrial Septal Defects

• Primum ASD: Associated with cleft mitral valve and marked LAD on ECG

• Secundum ASD: Most common with female predominance

• Sinus venosus ASD: Associated with partial anomalous venous return

• All have wide/fixed split of S2

MVP: A Syndrome with Too Many Names

• Myxomatous mitral valve prolapse

• Click/murmur syndrome

• Floppy mitral valve syndrome

• “Classic” MVP

• Barlow’s Syndrome

History of Mitral Valve Prolapse

• 1962 Barlow describes MVP syndrome

• 1970 VPC’s and sudden cardiac death

• 1976 Prevalance 5-15%???

• 1986 High risk markers for MVP complications identified

• 1989 Saddle shaped mitral annulus described

MVP: Clinical Exam

• Non-ejection click

• Mid-to-late systolic click

• Pansystolic murmur

• Mid-to-late systolic murmur

• Precordial “Honk”

• Changes with maneuvers

• “Silent” MVP

Complications of MVP Syndrome

• Ruptured chorda tendiniae

• Progressive mitral insufficiency

• Subacute bacterial endocarditis

• Sudden cardiac death

• Transient ischemic attacks

Complications in Classic and Nonclassic Mitral Valve Prolapse

Classic (N=319)

Nonclassic (N=137)

P Value

SBE 3.5% (11) 0 <0.02

Severe MR 11.9% (30) 0 <0.001

MV surgery 6.6% (21) 0.7% (1) <0.02

TIA/stroke 7.5% (24) 5.8% (8) ns

Hypertrophic Cardiomyopathy

• May occur with or without dynamic LVOT obstruction

• Systolic ejection murmur at lower left sternal border

• Murmur increases during Phase 2 of Valsalva

• Bisferiens pulse

Hypertrophic Cardiomyopathy Treatment: General Guidelines

• Physical Activity: Avoid strenuous activity (no competitive sports), avoid dehydration

• Endocarditis Risk: Dental care

• Genetic Counseling: Screen first degree relatives, pregnancy counseling

Hypertrophic Cardiomyopathy: Treatment

• General guidelines

• Medical therapy: Beta blockers, Ca channel blockers

• Catheter based septal ablation

• Surgical myectomy

• AICD implantation

HCM: ECG from 1995

HCM: ECG from 2002

HCM: ECG from January 2010

Is the Murmur Significant?

• Is the patient symptomatic?

• Are symptoms consistent with cardiac limitation?

• Is there cardiac enlargement or chamber enlargement on CXR or exam?

• Is there LVH or RVH on ECG?