Murmurs and Prosthetic Valves

Question 1

What is S1?

Answer 1

Closing of atrioventricular valves

Mitral and Tricuspid

Question 2

What is S2?

Answer 2

Closing of the semilunar valves

Aortic and Pulmonary

Question 3

What can a third heart sound indicate?

Answer 3

15-40 = normal
40+ = ?HF

Question 4

When is a fourth heart sound heard?

Answer 4

Directly before S1
Indicates stiff/hypetrophic ventricle
caused by turbulent flow from an atria contracting against a non-compliant ventricle

Question 5

Auscultation: Pulmonary valve

Answer 5

2nd I.C.S left sternal boarder

Question 6

Auscultation: Aortic valve

Answer 6

2nd I.C.S right sternal boarder

Question 7

Auscultation: Tricuspid valve

Answer 7

4th I.C.S left sternal boarder

Question 8

Auscultation: Mitral valve

Answer 8

5th I.C.S mid clavicular line (apex area)

Question 9

Where are S1 and S2 best heard?

Answer 9

ERb’s point

Third intercostal space on the left sternal boarder

Question 10

What can be done to emphasise different murmurs?

Answer 10

RILE
Right = Inspiration
Left = Expiration

Patient on left side (mitral stenosis)
Patient learning forward and holding exhalation (aortic regurgitation)

Question 11

Assessing a murmur

Answer 11

S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (AS) or left axilla (MR)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high pitched or low and grumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?

Question 12

Murmur grading

Answer 12

1. Difficult to hear
2. Quiet
3. Easy to hear
4. Easy to hear with a palpable thrill
5. Can hear with stethoscope barely touching chest
6. Can hear with stethoscope off the chest

Question 13

What valvular disease causes hypertrophy?

Answer 13

Mitral stenosis - left atrial hypertrophy

Aortic stenosis - left ventricular hypertrophy

Question 14

What valvular disease causes dilation?

Answer 14

Mitral regurgitation - left atrial dilatation

Aortic regurgitation - left ventricular dilatation

Question 15

Causes of Mitral stenosis

Answer 15

Rheumatic Heart Disease

Infective Endocarditis

Question 16

What type of murmur is mitral stenosis?

Answer 16

Mid-diastolic, low pitched “rumbling” murmur

Question 17

Associations in Mitral stenosis

Answer 17

Malar flush - back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation

AF - left atrium struggles to push blood through the stenotic valve causing strain and electrical disruption

Question 18

What type of murmur is mitral regurgitation?

Answer 18

pan-systolic, high pitched “whistling” murmur

Radiates to left axilla

Question 19

Causes of mitral regurgitation

Answer 19

Idiopathic weakening of the valve with age
Ischaemic heart disease
Infective Endocarditis
Rheumatic Heart Disease
Connective tissue disorders such as Ehlers Danlos or Marfans

Question 20

What type of murmur is aortic stenosis?

Answer 20

Ejection-systolic, high pitched murmur

crescendo-decrescendo character

Question 21

Signs of aortic stenosis

Answer 21

Murmur radiates to the carotids
Slow rising pulse and narrow pulse pressure
Patients may complain of exertional syncope

Question 22

Causes of aortic stenosis

Answer 22

Idiopathic age related calcification

Rheumatic Heart Disease

Question 23

What type of murmur is aortic regurgitation?

Answer 23

Early diastolic, soft murmur

Associated with a Corrigan’s pulse

Question 24

What is an Austin-Flint murmur?

Answer 24

Heard at the apex Early diastolic “rumbling” murmur

Caused by blood flowing back through the aortic valve and over the mitral valve causing it to vibrate

Question 25

Causes of aortic regurgitation

Answer 25

Idiopathic age related weakness

Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome

Question 26

Complications with mechanical heart valves

Answer 26

Thrombus formation (blood stagnates and clots)
Infective endocarditis (infection in prosthesis) 2.5%
Haemolysis

Question 27

Lifespan of replacement valve

Answer 27

Biosynthetic - 10 years

Mechanical - 20 year (warfarin lifelong)