During this week’s episode, we’ll be discussing valvular disorders, in essence, heart murmurs.

There are LOADS of Picmonics available for heart murmurs. A couple of my favorites Mitral Regurgitation and Aortic Stenosis.

Systole=ventricles contracting

Diastole=ventricles relaxing & refilling

S1=beginning of systole. AV valves (mitral & tricuspid) are closing. “lub”

S2=end of systole. Semilunar valves closing (aortic & pulmonic) “dub”

Lub, dub, rest, lub, dub, rest

Murmur Accentuation Maneuvers

The following applies to all murmurs except that of hypertrophic cardiomyopathy, in which the opposite is true

  • Position:

  • Aortic=increased with leaning forward

  • Mitral=LLD

  • Increased venous return

  • Squatting

  • Leg raise

  • Lying down

  • Later click in MVP

  • Inspiration

  • Right sided murmurs only

  • Also due to increased venous return

  • Expiration

  • Left sided murmurs only

  • Also due to increased venous return

  • Increased Afterload

  • Handgrip

  • Increases regurgitation murmurs

  • Pushes backward

Aortic Stenosis

  • 1 valvular disease

  • Etiologies:

  • Calcification

  • Bicuspid valve (if under 70y.o.)

  • Systolic, crescendo-descrescendo ejection murmur

  • At right upper sternal border (the location of the aortic valve)

  • With radiation to the carotids

  • Narrowed pulse pressure

  • Pulsus parvus et tardus

  • Small, delayed, carotid pulse

  • Not specific to aortic stenosis

  • Can lead to angina, syncope, LVH, and CHF

  • Tx:

  • VALVE REPLACEMENT

  • Once symptomatic

  • Mechanical valves (vs bioprosthetic) require lifelong anticoagulation

Mitral Stenosis

  • Etio: rheumatic heart disease

  • Early mid-diastolic rumble preceded by an opening snap

  • At apex (location of mitral valve)

  • Increased in left lateral decubitus position

  • Prominent S1 (stenotic mitral valve closes forcefully)

  • Symptoms

  • Pulmonary symptoms

  • Blood backs into lungs

  • Pulmonary htn

  • Atrial fibrillation

  • 2/2 atrial enlargement

  • “mitral facies”

  • Flushed cheeks with facial pallor

  • Treatment:

  • Percutaneous balloon valvuloplasty

  • Younger patients

  • Non-calcified valves

  • Valve replacement otherwise

Mitral Regurgitation

  • Etio:

  • mitral valve prolapse #1

  • papillary muscle dysfunction

  • ischemia/infarction

  • Blowing, holosystolic murmur

  • At Apex (location of mitral valve)

  • Radiation to axilla

  • Blowing=regurg

  • Widely split S2

  • Aortic valve closes early due to decreased LV ejection time

  • Pulmonic valve closes late due to pulmonary htn (increased pressure to overcome)

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