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Valvular Heart Disease
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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
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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
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Mild Aortic Stenosis
Mild Pulmonic Stenosis
Atrial Septal Defect
Mitral Valve Prolapse
Hypertrophic Cardiomyopathy
Question: Who warrants SBE prophylaxis?
SBE Prophylaxis-2007
Guidelines
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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
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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
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Myxomatous mitral valve prolapse
Click/murmur syndrome
Floppy mitral valve syndrome
“Classic” MVP
Barlow’s Syndrome
History of Mitral Valve Prolapse
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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
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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
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Ruptured chorda tendiniae
Progressive mitral insufficiency
Subacute bacterial endocarditis
Sudden cardiac death
Transient ischemic attacks
Complications in Classic and
Nonclassic Mitral Valve Prolapse
Nonclassic
(N=137)
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P Value
SBE
Classic
(N=319)
3.5% (11)
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
<0.02
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?