Valvular Heart Disease

• 3rd Heart Sound

  • Heard roughly 0.1 seconds after the second heart sound
  • Rapid ventricular filling causing the chordae tendineae to pull to their full length and twang like a guitar string
  • Can be normal in young healthy people (15-40 years) but can indicate heart failure in older patients
• Normal Heart Sounds

  • First heart sound (S1) is caused by the closing of the atrioventricular valves (tricuspid and mitral valves) at the start of the systolic contraction of the ventricles
  • Second heart sound (S2) is caused by the closing of the semilunar valves (pulmonary and aortic valves) once the systolic contraction is complete
• 4th Heart Sound

  • Heard directly before S1
  • Always abnormal and relatively rare to hear
  • Indicates a stiff or hypertrophic ventricle and caused by turbulent flow from the atria contracting against a non-compliant ventricle
• Listening to Murmurs: Auscultate with the stethoscope bell to better hear low-pitched sounds and the diaphragm to listen to high-pitched sounds
• Listening to murmurs

  Listen over the 4 valve areas in turn for murmurs: Pulmonary area, Aortic, Tricuspid, Mitral. Listen to Erb’s point. Special manoeuvres can be used to emphasise certain murmurs
• A fourth heart sound is always abnormal and relatively rare to hear
• Special manoeuvres for emphasising murmurs

  Position the patient on their left side for mitral stenosis, position the patient sat up, leaning forward and holding exhalation for aortic regurgitation
• Valvular heart disease can cause

  Hypertrophy (thickening both outwards and into the chamber) or dilatation (thinning and expanding) of the myocardium in different heart areas
• Murmur Grade

  • Grade I: Difficult to hear, Grade II: Quiet, Grade III: Easy to hear, Grade IV: Easy to hear with a palpable thrill, Grade V: Audible with stethoscope barely touching the chest, Grade VI: Audible with stethoscope off the chest
• Valve areas to listen for murmurs

  • Pulmonary area, Aortic, Tricuspid, Mitral
• Assessing a Murmur

  Use the "SCRIPT" mnemonic: Site, Character, Radiation, Intensity, Pitch, Timing. Grading a murmur is subjective but helpful in assessing the severity of the defect
• A fourth heart sound (S4) is heard directly before S1
• A fourth heart sound indicates a stiff or hypertrophic ventricle and is caused by turbulent flow from that atria contracting against a non-compliant ventricle
• To remember the stethoscope usage, think of a child’s high-pitched screaming from their diaphragm and a church bell giving a deep “bong”
• Describing a Murmur

  Use a script to describe a murmur in exams or OSCE practice sessions
• When pushing against a stenotic valve

  The muscle has to try harder, resulting in hypertrophy. Mitral stenosis causes left atrial hypertrophy
• Aortic stenosis causes

  Left ventricular hypertrophy
• Mitral regurgitation causes

  Left atrial dilatation
• When pushing against a stenotic valve

  The muscle has to try harder, resulting in hypertrophy
• Aortic stenosis is the most common valvular heart disease and the most common indication for valve replacement surgery. It refers to narrowing of the aortic valve, restricting blood flow from the left ventricle to the aorta
• The murmur radiates to the carotids as the turbulence continues into the neck
• Signs of aortic regurgitation

  • Thrill in the aortic area on palpation
  • Collapsing pulse
  • Wide pulse pressure
  • Heart failure
  • Pulmonary oedema
• Signs of mitral stenosis

  • Tapping apex beat
• Causes of aortic stenosis

  • Idiopathic age-related calcification
  • Bicuspid aortic valve
  • Rheumatic heart disease
• Mitral stenosis is a narrowed mitral valve restricting blood flow from the left atrium into the left ventricle
• Aortic regurgitation typically causes an early diastolic, soft murmur
• Aortic regurgitation refers to an incompetent aortic valve, allowing blood to flow back from the aorta into the left ventricle
• When a leaky valve allows blood to flow back into a chamber

  It stretches the muscle, resulting in dilatation
• Aortic stenosis causes an ejection-systolic, high-pitched murmur due to the high blood flow velocity through the aortic valve. This has a crescendo-decrescendo character due to the speed of blood flow across the value during the different periods of systole. Flow during systole is slowest at the start and end and fastest in the middle
• Signs of aortic stenosis

  • Thrill in the aortic area on palpation
  • Slow rising pulse
  • Narrow pulse pressure
  • Exertional syncope
• Mitral stenosis causes

  Left atrial hypertrophy
• Aortic regurgitation can also cause an Austin-Flint murmur. This is heard at the apex as a diastolic “rumbling” murmur. This is caused by blood flowing back through the aortic valve and over the mitral valve, causing it to vibrate
• Causes of aortic regurgitation

  • Idiopathic age-related weakness
  • Bicuspid aortic valve
  • Connective tissue disorders such as Ehlers-Danlos syndrome and Marfan syndrome
• Aortic regurgitation causes

  Left ventricular dilatation
• Mitral stenosis causes a mid-diastolic, low-pitched “rumbling” murmur due to a low blood flow velocity. There will be a loud S1 due to thick valves requiring a large systolic force to shut, then shutting suddenly. There is an opening snap after S2, which triggers the onset of the murmur
• Atrial fibrillation

  Irregularly irregular pulse caused by the left atrium struggling to push blood through the stenotic valve, resulting in strain, electrical disruption, and fibrillation
• TOM TIP: 'When examining a patient with heart valve pathology, look for signs of the potential underlying cause. For example, look for signs of infective endocarditis in a patient with mitral stenosis, such as splinter haemorrhages, Janeway lesions, Osler’s nodes, and splenomegaly, and offer fundoscopy for Roth spots. Look for signs of Marfan syndrome in a patient with aortic regurgitation, such as tall stature, long limbs, arachnodactyly (long slender fingers), and a high-arched palate. This will make you look very clever.'
• Mitral regurgitation

  Causes a reduced ejection fraction and a backlog of blood waiting to be pumped through the left side of the heart, resulting in congestive cardiac failure
• Other signs of mitral stenosis

  • Tapping apex beat
  • Malar flush
  • Atrial fibrillation
• Causes of mitral regurgitation

  • Idiopathic weakening of the valve with age
  • Ischaemic heart disease
  • Infective endocarditis
  • Rheumatic heart disease
  • Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome