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Heart Valves & Cardiac AuscultationHeart Valves & Cardiac Auscultation
A. Bornstein, M.D., F.A.C.C.A. Bornstein, M.D., F.A.C.C.Assistant Professor of Science EducationAssistant Professor of Science EducationHofstra North Shore-LIJ School of MedicineHofstra North Shore-LIJ School of MedicineHempstead, NYHempstead, NY
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Cardiac MurmursCardiac Murmurs•Auscultatory sound: cardiac or vascular origin of Auscultatory sound: cardiac or vascular origin of short durationshort duration • Cardiac murmurs are audible turbulent sound waves in the range of 20-Cardiac murmurs are audible turbulent sound waves in the range of 20-
20,000 cycles/second; often, 20,000 cycles/second; often, first signfirst sign of underlying valvular pathology of underlying valvular pathology
•May be May be systolicsystolic or or diastolicdiastolic, , pathologicalpathological or or benignbenign
• Systolic murmurs may be due to physiological increases in Systolic murmurs may be due to physiological increases in blood flow blood flow velocityvelocity or might indicate an as yet or might indicate an as yet asymptomaticasymptomatic cardiac disease cardiac disease
•Diastolic murmurs and most continuous murmurs are almost Diastolic murmurs and most continuous murmurs are almost always always pathologicalpathological and require further evaluation and require further evaluation
• ECGECG & & CXRCXR provide some limited diagnostic information and are readily provide some limited diagnostic information and are readily available testsavailable tests
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Characteristics of MurmursCharacteristics of Murmurs
• Benign murmur:Benign murmur:- Early to mid peaking systolicEarly to mid peaking systolic- Soft (I-II/VI)Soft (I-II/VI)- Varies with respirationVaries with respiration- Presents during normal exam and work-upPresents during normal exam and work-up
• Pathologic murmur: Pathologic murmur: - All diastolic murmursAll diastolic murmurs- All pansystolic murmurs (holosystolic murmurs) All pansystolic murmurs (holosystolic murmurs) - Late peaking systolic murmursLate peaking systolic murmurs- Very loud murmurs (III-V/VI)Very loud murmurs (III-V/VI)- Continuous murmursContinuous murmurs
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Grading of Heart Murmurs Grade I-Grade VIGrading of Heart Murmurs Grade I-Grade VI
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Turbulent Flow vs. Laminar FlowTurbulent Flow vs. Laminar Flow• Normally, blood flow is laminar; with Normally, blood flow is laminar; with
flow velocity flow velocity across valve or across valve or valve orifice valve orifice (stenosis), laminar flow (stenosis), laminar flow is disrupted is disrupted turbulence turbulence murmur; murmur; blood does not flow linearly & smoothly blood does not flow linearly & smoothly in adjacent layers; instead flow becomes in adjacent layers; instead flow becomes chaoticchaotic
• TurbulenceTurbulence: : energy needed to drive energy needed to drive blood flow because turbulence blood flow because turbulence loss loss of energy as friction, (generates heat); of energy as friction, (generates heat); when plotting a pressure-flow when plotting a pressure-flow relationship, turbulence relationship, turbulence perfusion perfusion pressure needed to drive a given flow; pressure needed to drive a given flow; at any given perfusion pressure, at any given perfusion pressure, turbulence leads to turbulence leads to in flow in flow
• Magnitude of perfusion Magnitude of perfusion pressure gradientpressure gradient depends on severity of depends on severity of valve stenosisvalve stenosis and and flow rate or flow rate or flow velocity flow velocity
V = Q/tV = Q/t
Q = A VQ = A V
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Turbulent Flow vs. Laminar FlowTurbulent Flow vs. Laminar Flow• Normally, blood flow is Normally, blood flow is laminarlaminar; ;
with with flow flow across valve or across valve or valve orifice valve orifice (stenosis), laminar flow (stenosis), laminar flow is disrupted is disrupted turbulence turbulence murmur; murmur; blood does not flow linearly & smoothly blood does not flow linearly & smoothly in adjacent layers; instead flow in adjacent layers; instead flow becomes chaoticbecomes chaotic
• Turbulence: Turbulence: energy needed to drive energy needed to drive blood flow because turbulence blood flow because turbulence loss loss of energy as of energy as frictionfriction, (generates , (generates heatheat); when plotting a pressure-); when plotting a pressure-flow relationship, turbulence flow relationship, turbulence perfusion pressureperfusion pressure needed to drive a needed to drive a given flow; at any given perfusion given flow; at any given perfusion pressure, turbulence leads to pressure, turbulence leads to in flow in flow
• Magnitude of perfusion Magnitude of perfusion pressure pressure gradientgradient depends on severity of depends on severity of valve valve stenosisstenosis and flow rate or and flow rate or flow velocity flow velocity
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Thoracic LandmarksThoracic Landmarks
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Thoracic LandmarksThoracic Landmarks
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Cardiac Timing CyclesCardiac Timing Cycles
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Examples of MurmursExamples of Murmurs
• Benign:Benign:— Flow murmurFlow murmur
• Pathologic:Pathologic:— Diastolic murmur: MS; TS; AI; PIDiastolic murmur: MS; TS; AI; PI— Pansystolic (holosystolic) murmur: MR; TR; VSDPansystolic (holosystolic) murmur: MR; TR; VSD— Loud murmurs: > III/VILoud murmurs: > III/VI— Continuous murmur: patent ductus arteriosus (PDA) Continuous murmur: patent ductus arteriosus (PDA)
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Phonocardiograms From Normal & Abnormal Heart SoundsPhonocardiograms From Normal & Abnormal Heart Sounds
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Murmurs, Extra Sounds, and Murmurs, Extra Sounds, and Cardiac Auscultation Timing CyclesCardiac Auscultation Timing Cycles
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Timing Auscultatory Events by Timing Auscultatory Events by Carotid Artery & Jugular Venous Pulse Carotid Artery & Jugular Venous Pulse
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Murmurs by Position: Systolic MurmursMurmurs by Position: Systolic Murmurs
• Right upper sternal border (RUSB)Right upper sternal border (RUSB)- Aortic stenosis (AS)Aortic stenosis (AS)
• Left upper sternal border (LUSB)Left upper sternal border (LUSB)- Pulmonary insufficiency (PI)Pulmonary insufficiency (PI)
• Left lower sternal border (LLSB)Left lower sternal border (LLSB)- Tricuspid regurgitation (TR)Tricuspid regurgitation (TR)- Ventricular septal defect (VSD)Ventricular septal defect (VSD)- Hypertrophic cardiomyopathy (HCM)Hypertrophic cardiomyopathy (HCM)
• ApexApex- Mitral regurgitation (MR)Mitral regurgitation (MR)
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Murmurs by Position: Diastolic MurmursMurmurs by Position: Diastolic Murmurs
• Left upper sternal border (LUSB)Left upper sternal border (LUSB)– Pulmonary insufficiency (PI)Pulmonary insufficiency (PI)
• Left lower sternal border (LLSB) Left lower sternal border (LLSB) – Tricuspid stenosis (TS)Tricuspid stenosis (TS)
• ApexApex– Mitral stenosis (MS)Mitral stenosis (MS)
• 33rdrd intercostal space (ICS), lower sternal border (LSB) intercostal space (ICS), lower sternal border (LSB)– Aortic Insufficiency (AI)Aortic Insufficiency (AI)
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Continuous MurmursContinuous Murmurs
• Require continuous pressure gradient for continuous blood flowRequire continuous pressure gradient for continuous blood flow
• Occurs at artery-vein connectionsOccurs at artery-vein connections– Patent ductus arteriosus (PDA)Patent ductus arteriosus (PDA)– Arteriovenous malformation (AVM)Arteriovenous malformation (AVM)– Venous humVenous hum
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Aortic StenosisAortic Stenosis
Aortic areaAortic area
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Aortic StenosisAortic Stenosis
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Degenerative calcific aortic stenosisDegenerative calcific aortic stenosis Congenital aortic stenosis Congenital aortic stenosis (unicuspid valve)(unicuspid valve)
Congenital aortic stenosis Congenital aortic stenosis (bicuspid valve)(bicuspid valve)
Normal aortic valveNormal aortic valveNormal aortic valveNormal aortic valve
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Aortic Flow Murmur vs. Aortic StenosisAortic Flow Murmur vs. Aortic Stenosis
Normal aortic valve Normal aortic valve with flow murmurwith flow murmur
Stenotic aortic valve Stenotic aortic valve with pathologic murmurwith pathologic murmur
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Summary of Systolic MurmursSummary of Systolic Murmurs
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Summary of Diastolic MurmursSummary of Diastolic Murmurs
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Pulse Characteristics: Normal & Aortic Valve DiseasePulse Characteristics: Normal & Aortic Valve Disease
3) Aortic insufficiency3) Aortic insufficiency
2) Aortic stenosis2) Aortic stenosis1) Normal1) Normal
Carotid pulseCarotid pulseBrachial pulse: Brachial pulse:
combined AS & AR combined AS & AR
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Valve Lesions & Hemodynamics (Aortic Stenosis)Valve Lesions & Hemodynamics (Aortic Stenosis)
Normal pressuresNormal pressures Aortic stenosisAortic stenosis
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Aortic Stenosis & MurmurAortic Stenosis & MurmurMurmurs of aortic stenosisMurmurs of aortic stenosis Aortic stenosisAortic stenosis
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Aortic Stenosis & MurmurAortic Stenosis & Murmur
Murmurs of aortic stenosisMurmurs of aortic stenosis Aortic stenosis hemodynamicsAortic stenosis hemodynamics
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Early Ejection Click & Systolic Ejection MurmurEarly Ejection Click & Systolic Ejection Murmur
Stenotic bicuspid aortic valve with ejection click Stenotic bicuspid aortic valve with ejection click
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Systolic Ejection Murmur: Severe Aortic Stenosis Systolic Ejection Murmur: Severe Aortic Stenosis
Aortic Aortic pressurepressure
LV LV pressurepressure
•Aortic stenosis is most often diagnosed while still asymptomaticAortic stenosis is most often diagnosed while still asymptomatic•Systolic crescendo-decrescendo murmur is audible at the RUSB, radiating to carotid arteries Systolic crescendo-decrescendo murmur is audible at the RUSB, radiating to carotid arteries •Pressure differentials between LV & aorta, obtained at catheterization, pathognomonic for ASPressure differentials between LV & aorta, obtained at catheterization, pathognomonic for AS
Transvalvular Transvalvular gradientgradient
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Critical Aortic Stenosis: Transvalvular GradientCritical Aortic Stenosis: Transvalvular Gradient
LALA
LVLV
AortaAorta
ApexApexESES
MSMMSMSS11SS22
LVEDPLVEDP
Transvalvular Transvalvular gradientgradient
Transvalvular Transvalvular gradientgradient
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Critical Aortic Stenosis: Transvalvular GradientCritical Aortic Stenosis: Transvalvular Gradient
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Bicuspid Aortic Valve With Aortic RegurgitationBicuspid Aortic Valve With Aortic Regurgitation
(Tricuspid) rheumatic or (Tricuspid) rheumatic or degenerative aortic valvedegenerative aortic valve
Congenital bicuspid Congenital bicuspid aortic valveaortic valve
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Valve Lesions & Hemodynamics (AR)Valve Lesions & Hemodynamics (AR)Normal pressuresNormal pressures Aortic regurgitationAortic regurgitation
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Aortic Regurgitation HemodynamicsAortic Regurgitation Hemodynamics
Aortic regurgitation on MRAAortic regurgitation on MRA
Upsloping LV Upsloping LV diastolic pressurediastolic pressure
Wide pulse pressureWide pulse pressure
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Acute Versus Chronic Aortic RegurgitationAcute Versus Chronic Aortic Regurgitation
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Mitral RegurgitationMitral Regurgitation
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Overall Causes of Mitral RegurgitationOverall Causes of Mitral Regurgitation
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Causes of Mitral InsufficiencyCauses of Mitral Insufficiency
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Causes of Severe Mitral RegurgitationCauses of Severe Mitral Regurgitation
MV leaflet perforationMV leaflet perforation Papillary muscle infarctPapillary muscle infarct
mitral annular calcificationmitral annular calcificationBillowing mitral leaflets (MVP)Billowing mitral leaflets (MVP)
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Mitral Stenosis & Regurgitation Mitral Stenosis & Regurgitation
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Myxomatous MVP: Forms of Mitral RegurgitationMyxomatous MVP: Forms of Mitral Regurgitation
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Valve Lesions & Hemodynamics (MR)Valve Lesions & Hemodynamics (MR)
Normal pressuresNormal pressures Mitral regurgitationMitral regurgitation
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Acute Versus Chronic Mitral RegurgitationAcute Versus Chronic Mitral Regurgitation
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Carotid Pulse & Cardiac Auscultation Carotid Pulse & Cardiac Auscultation in Critical AS versus Acute MR in Critical AS versus Acute MR
1) Critical aortic stenosis1) Critical aortic stenosis
2) Acute mitral regurgitation2) Acute mitral regurgitation
AS or Acute MR??AS or Acute MR??
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Summary of Systolic MurmursSummary of Systolic Murmurs
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Mitral StenosisMitral Stenosis
Aortic Aortic pressurepressure
LV LV pressurepressure
LVDM LVDM pressurepressure
Mitral stenosisMitral stenosis
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Mitral StenosisMitral Stenosis
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Critical Mitral Stenosis Critical Mitral Stenosis
Mitral stenosis chest X-ray: P-A viewMitral stenosis chest X-ray: P-A view
Mitral stenosis: Mitral stenosis: superior viewsuperior view
Rheumatic Rheumatic heart disease heart disease with mitral with mitral stenosisstenosis
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Severe Longstanding Mitral StenosisSevere Longstanding Mitral Stenosis
Mitral stenosis in the parasternal long axisMitral stenosis in the parasternal long axis Mitral stenosis in the apical 4 chamber viewMitral stenosis in the apical 4 chamber view
Normal mitral in the parasternal long axisNormal mitral in the parasternal long axis Normal mitral in the apical 4 chamber viewNormal mitral in the apical 4 chamber view
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Valve Lesions & Hemodynamics (Mitral Stenosis)Valve Lesions & Hemodynamics (Mitral Stenosis)
Normal pressuresNormal pressures Mitral stenosisMitral stenosis
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Normal MV Function vs. Mitral StenosisNormal MV Function vs. Mitral Stenosis
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Mitral StenosisMitral Stenosis
Pre balloon Pre balloon angioplastyangioplasty
Post balloon Post balloon angioplastyangioplasty
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Summary of Diastolic MurmursSummary of Diastolic Murmurs
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Percutaneous Aortic Valve ImplantationPercutaneous Aortic Valve Implantation
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Percutaneous Aortic Valve ImplantationPercutaneous Aortic Valve Implantation
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Mitral regurgitationMitral regurgitation
Mitral stenosisMitral stenosis
Aortic regurgitationAortic regurgitation
Aortic StenosisAortic Stenosis
