Download Diagnosis of valvular diseases

Diagnosis of valvular diseases
Dr. Szathmári Miklós
Semmelweis University
First Department of Medicine
24. Oct. 2011.
Normal heart sounds
First heart sound
(S1)
Lub
Closure of the mitral
and tricuspidal valves
Start of the systole
Second heard sound
(S2)
Dub
Closure of semilunar
valves
Start of the diastole
Identification of heart sounds
The systolic sound (S1) longer, deeper and softer,
than S2 (beat-like, dobbanás-szerű). The
diastolic sound (S2) is shorter, higher, and sharp
(clicking-like, koppanás-szerű)
• The diastolic interval (S2 – S1) is longer, than
the systolic (S1-S2)
• The carotid artery pulse or apical impulse occur
in early systole, right after the first heart sound
• S1 is usually louder than S2 at the apex, and S2
is usually louder than S1 at the base.
Extra heart sounds in diastole
• S3- ventricular galopp –
It is heard best at the
apex in the left lateral
position.It is louder on
inspiration. Dull, low –
pitched. Over 40 year of
age is almost certainly
pathologic. Causes:
decreased myocardial
contractility, myocardial
failure, and volume
ovarload of a ventricle, as
from mitral or tricuspid
regurgitation.
Global burden of valvular heart
disease
• Primary valvular heart disease ranks below coronary
heart disease, stroke, hypertension, obesity, and
diabetes as major threats to the public health.
• Rheumatic fever is the dominant cause of valvular heart
disease in developing countries. Prevalence and
mortality rates vary according to the availability of
medical resources and population-wide programs for
detection and treatment of group A streptococcal
pharyngitis.
• Valve disease in developed countries is dominated by
degenerative or inflammatory processes that lead to
valve tickening, calcification, and dysfunction.
• Left-sided valve disease may affect as many as 12-13%
of adults over the age of 75.
Mitral stenosis
•
Presystolic murmur
– Low pitched, rumbling
– In left lateral position, during
exersice, and after complete
exhalation is heard better.
•
S1 is accentuated and
delayed:
– The mitral valve is still open
wide at the onset of ventricular
systole and closes quickly
•
P2 is accentuated:
– Pulmonary hypertension
develops
•
Opening snap
– Very early diastolic sound
produced by the opening of a
stenotic mitral valve.
– It is heard best just medial to
the apex
– High pitch and snapping
quality, it is heard better with
the diaphragma
•
Middiastolic murmur)
– Usually limited to the apex
– Little or non radiation
Mitral stenosis
• Associated signs:
– Malar flush with perioral pallor
– In case of right-sided heart failure peripheral edema,
hepatomegaly, ascites and pleural effusion
– With severe pulmonary hypertension, a pansystolic murmur
produced by functional tricuspidal regurgitation.
– Graham-Steel murmur of PR, a high-pitched, diastolic,
decrescendo blowing murmur along the left sternal border
because of dilatation of the pulmonary valve ring
– Atrial fibrillation
– The left ventricle is smaller, the right ventricle is hypertrophic.
– The systemic arterial pressure is normal or slightly low.
Mitral regurgitation
• Holosystolic murmur
– Maximal intensity at the apex
– Blowing quality, medium to
high pitch. If loud associated
with an apical thrills
– Radiation to the left axilla, less
often to the left sternal border
– An apical S3 reflects the
volume overload on the left
ventricle
– The S1 is often decreased
(calcified and relatively
inmobile mitral valve)
– Unlike the murmur of tricuspid
regurgitation, it does not
become louder in inspiration
– Wide splitting of 2nd heart
sound because of the early
closure of aortic valve
Causes of mitral regurgitation
• Acute mitral regurgitation:
– acute myocardial infarction with papillary muscle
rupture, or during the course of infective endocarditis
• Transient, acute mitral regurgitation:
– during periods of acute ischaemia and bouts of
angina pectoris
• Chronic mitral regurgitation can result from
– rheumatic disease (more frequently in males)
– extensive mitral annular calcification (among patients
with advanced renal disease, and is commonly
observed in elderly women with hypertension and
diabetes)
– hypertrophic obstructive cardiomyopathy
– dilated cardiomyopathy (The annular dilatation and
ventricular remodeling causes papillary muscle
displacement and fibrosis)
Symptoms of mitral regurgation
• Chronic mild-to-moderate MR is usually
asymptomatic (well tolerated volume overload of
LV)
• Severe MR: fatique, exertional dyspnea,
orthopnea, palpitation
• In case of marked pulmonary hypertension:
painful hepatic congestion, anckle edema,
distended neck veins, ascites
• In case of acute MR the acute pulmonary edema
is common
Aortic stenosis
May be due to degenerative calcification of aortic cusps, or
congenital in origin, or it may be secondary to rheumatic
inflammation. Calcific AS is progressive disease, with an annual
reduction in valve area averaging 0.1 cm2/year.
Etiology of aortic stenosis
• Due to degenerative calcification of aortic cusps
– Congenital
– Secondary to rheumatic inflammation
• Age-related degenerative
– About 30% of persons >65 years exhibit aortic valve
sclerosis
– Many of these have a systolic murmur of AS without
obstruction
– 2% exhibit frank stenosis
Aortic stenosis
– Frequently, an S4 is audable at
the apex, and reflects the
presence of left ventricle
hypertrophy and an elevated left
ventricle end-diastolic pressure;
– Protosystolic ejection sound
(aortic stenosis,dilated aorta,
pulmonic stenosis). Relatively
high in pitch with a sharp, clicking
quality
– crescendo-decrescendo
ejection murmur
- Loud, harsh murmur. Maximal
intensity at the right 2nd
interspace
• Often accompanies by palpable
thrills
• Radiation often to the neck
• Heard best with the patient sitting
and leaning forward, after
complete exhalation.
• The intensity of the murmur
decreases in upright position and
during exercise
Extra heart sounds in diastole
• S4 – atrial galopp – just
before S1. It is heard best
at the apex in the left
lateral postion. Dull, lowpitched sound. It is due to
increased resistance to
ventricular filling following
atrial contraction.
(increased stiffness of
ventricular myocardium)
Hypertensive heart
diasese, coronary artery
disease, aortic stenosis,
and cardiomyopathy.
Symptoms of aortic stenosis
• Associated signs (even severe AS may exist for many
years without producing any symptoms because of the
ability of the hypertrophied left ventricle to generate
the elevated intraventricular pressures required for a
normal stroke volume)
– Dyspnea results from elevation of the pulmonary capillary pressure
– Angina pectoris partly because of the compression of the
coronary vessels by the hypertrophied myocardium
– Exertional syncope: result from a decline in arterial pressure
– The peripheral pulse rises slowly to a delayed sustained peak
(pulsus parvus et tardus)
– In the late stages, when stroke volume declines, the systolic
pressure may fall and the pulse pressure narrow
– Functional aortic regurgitation,with early decrescendo diastolic
murmur.
Causes of aortic regurgitation
• Primary valve disease (3/4 of patients with
pure valvular AR are males)
– Rheumatic origin (mostly with associated mitral valve
diasease)
– Infective endocarditis
• Primary aortic root disease
– Due to marked aortic dilatation (widening of the aortic
annulus and separation of the aortic leaflets)
•
•
•
•
•
Idiopathic
Marfan’s syndrome
Osteogenesis imperfecta
Syphilis
Ankylosing spondylitis
Aortic regurgitation
• S4
– Midsystolic murmur (relative
aortic stenosis)
• increased forward flow across
the aortic valve
• Early diastolic decrescendo
murmur
• Blood regurgitates from the aorta
back into the left ventricle
• 2nd to 4th left interspaces
parasternally
• Radiation to the apex (if loud)
• High pitch
• It is heard best with the patient
sitting, leaning forward, with
breath held in exhalation
– Mitral diastolic (Austin Flint)
murmur
• Diastolic impingement of the
regurgitant flow on the anterior
leaflet of the mitral valve (mitral
stenosis)
Aortic regurgitation
• The arterial pulse pressure is widened, and there is an
elevation of systolic pressure, and a depression of the
diastolic pressure.
• Rapidly rising pulse, which collapses suddenly as arterial
pressure falls rapidly during late systole and diastole
(Corrigan’s pulse, (pulsus celer et altus)
• Bobbing motion of the head with each systole (Musset’s
sign)
• Capillary pulsations, an alternate flushing and paling of the
skin at the root of the nail while pressure is applied to the tip
of the nail is characteristic (Quincke’s pulse)
• If the femoral artery is lightly compressed with the
stethoscope a systolo-diastolic murmur is audible
(Duroziez’s sign)