3. What are the physical examination findings in MS, MR, AR 3. What are the physical examination findings in MS, MR, AR? Draw the auscultogram of the cardiac findings.

MITRAL STENOSIS Early MS - loud S1 Opening snap heard after the S2 when listening at the apex Murmur is a low-pitched diastolic rumble best appreciated with the patient lying on the left side listening with the bell of the stethoscope positioned at the apex The intensity of the murmur does not correlate with severity; however, the duration of the murmur directly correlates with the severity of MS. Early MS - loud S1 because the increased left atrial pressure prevents the calcified leaflets from closing at the end of diastole. Systole closes the widely separated leaflets, which produces a loud first heart sound. As the disease progresses, the valve leaflets become heavily calcified and ridged and no longer open widely. Accordingly, the first sound becomes softer. Opening snap can be appreciated in mild to moderate MS while the leaflets are still mobile. It is heard after the S2 when listening at the apex with the diaphragm of the stethoscope. • The murmur of MS is characterized by a low-pitched diastolic rumble best appreciated with the patient lying on the left side listening with the bell of the stethoscope positioned at the apex. The intensity of the murmur does not correlate with severity; however, the duration of the murmur directly correlates with the severity of MS.

MITRAL REGURGITATION Holosystolic murmur at the apex of the heart which may radiate to the axilla or the entire precordium. The intensity of the murmur does not correlate with the severity of the MR. Severe MR may also produce a short diastolic murmur after the third heart sound that is not associated with mitral stenosis. Mitral regurgutation is typically characterized by a holosystolic murmur at the apex of the heart, which may radiate to the axilla or the entire precordium. • Abnormalities of the posterior MV leaflet may cause an anterior directed regurgitant jet and produce a murmur along the sternal border. This murmur can mimic the murmurs of tricuspid regurgitation or aortic stenosis. • Abnormalities of the anterior MV leaflet may result in a MR murmur that radiates to the back. • The intensity of the murmur does not correlate with the severity of the MR. • The murmur may not be holosystolic. For example, the murmur associated with MVP or papillary muscle dysfunction may occur in early, mid-, or late systole. • Severe MR may also produce a short diastolic murmur after the third heart sound that is not associated with mitral stenosis. • Auscultation maneuvers may help to distinguish the murmur of MR from other cardiac anomalies. _ Conditions that reduce preload (standing, early phase of the Valsalva maneuver) or afterload (amyl nitrate) reduce the intensity of the murmur. _ Maneuvers that increase preload (squatting) or afterload (isometric exercise) increase the intensity of the murmur. _ The late systolic murmur of MVP and hypertrophic cardiomyopathy alternatively increase with standing. • The first heart sound may be reduced because the mitral leaflets do not close completely. • The second heart sound may be widely split because the aortic valve closes earlier in diastole. • If pulmonary hypertension exists, the pulmonary component of the second heart sound is prominent. • Rapid ventricular filling may produce a third heart sound. • Severe MR produces brisk carotid upstrokes unless there is significant LV dysfunction. • Severe MR also produces a hyperdynamic cardiac impulse; whereas left ventricular dysfunction weakens the cardiac impulse.

MITRAL REGURGITATION First heart sound may be reduced because the mitral leaflets do not close completely Second heart sound may be widely split because the aortic valve closes earlier in diastole If pulmonary hypertension exists, the pulmonary component of the second heart sound is prominent Rapid ventricular filling may produce a third heart sound Severe MR: brisk carotid upstrokes unless there is significant LV dysfunction hyperdynamic cardiac impulse

AORTIC REGURGITATION ACUTE AORTIC REGURGITATION soft or silent S1, due to early closure of the mitral valve because of the increase in LVEDP. there may be an early diastolic murmur, which is much shorter than that of chronic aortic regurgitation, due to rapid equalization of pressure between the aorta and left ventricle. ACUTE AORTIC REGURGITATION • The patient will appear ill and exhibit cyanosis, tachycardic, and hypotension. The classic signs and symptoms of congestive heart failure will be present. • Cardiac auscultation may reveal a soft or silent S1, due to early closure of the mitral valve because of the increase in LVEDP. • In addition, there may be an early diastolic murmur, which is much shorter than that of chronic aortic regurgitation, due to rapid equalization of pressure between the aorta and left ventricle.

AORTIC REGURGITATION CHRONIC AORTIC REGURGITATION A2 is usually soft or inaudible, an S3 may be present diastolic murmur begins immediately after A2. It is a high-pitched decrescendo murmur heard best when the patient is leaning forward and exhaling Palpation of the chest may reveal a hyperdynamic and laterally displaced ventricular apex A systolic thrill may be appreciated at the base of the heart, related to the augmented stroke volume systolic murmur may be present because of turbulence induced by the large stroke volume A severe aortic regurgitant jet may impinge on the anterior mitral valve leaflet, narrowing the mitral valve orifice.causing a mid-diastolic low pitched murmur referred to as the Austin Flint murmur CHRONIC AORTIC REGURGITATION • On auscultation A2 is usually soft or inaudible, an S3 may be present. • The diastolic murmur of AR begins immediately after A2. It is a high-pitched decrescendo murmur heard best when the patient is leaning forward and exhaling. • If the disease is valvular in origin the murmur is best heard at the left sternal border. However if the aortic root is involved, the murmur is often heard best at the right sternal border. • A systolic murmur may be present because of turbulence induced by the large stroke volume. • A severe aortic regurgitant jet may impinge on the anterior mitral valve leaflet, narrowing the mitral valve orifice. This may cause a mid-diastolic lowpitched murmur referred to as the Austin Flint murmur. • Palpation of the chest may reveal a hyperdynamic and laterally displaced ventricular apex. • A systolic thrill may be appreciated at the base of the heart, related to the augmented stroke volume. • Peripheral signs of AR can be striking secondary to a widened pulse pressure and hyperdynamic circulation. These include: _ Corrigan’s pulse or water-hammer pulse: an abrupt rise in systolic pressure because of a large stroke volume followed by a rapid descent in diastolic pressure because of regurgitant flow. _ Bisferiens pulse: two distinct impulses with each beat. _ Traube sign: prominent systolic and diastolic sounds heard over the femoral arteries. _ Duroziez sign: associated with a systolic murmur audible over the femoral artery when compressed proximally and a diastolic murmur when compressed distally. _ The Quincke sign: characterized by visible capillary pulsation seen in the patient’s lip when a glass slide is placed over the lip or when the fingernails are gently compressed.

AORTIC REGURGITATION • Peripheral signs of AR can be striking secondary to a widened pulse pressure and hyperdynamic circulation. Corrigan’s pulse or water-hammer pulse: an abrupt rise in systolic pressure because of a large stroke volume followed by a rapid descent in diastolic pressure because of regurgitant flow Bisferiens pulse: two distinct impulses with each beat Traube sign: prominent systolic and diastolic sounds heard over the femoral arteries Duroziez sign: associated with a systolic murmur audible over the femoral artery when compressed proximally and a diastolic murmur when compressed distally The Quincke sign: characterized by visible capillary pulsation seen in the patient’s lip when a glass slide is placed over the lip or when the fingernails are gently compressed

Auscultogram S1 S2 OS S1 S2

10. How do you manage the patient on the following conditions: CHF. RF 10. How do you manage the patient on the following conditions: CHF? RF? Tight MS?

Medical treatment - slowing the heart rate and preventing complications of the disease beta blockers or calcium channel blockers can slow the heart rate allowing better left ventricular filling. Because most patients have had rheumatic fever - prophylax against recurrent rheumatic fever. Treated as high risk for endocarditis.

Medical intervention Asymptomatic yearly follow-up care; physical examination, chest radiography, and echocardiography. For the patient with signs or symptoms of CHF, diuretics may provide benefit. Tachyarrhythmias require medical treatment aimed at restoration and maintenance of sinus rhythm. Decrease ventricular response and maintain an acceptable heart rate Digoxin, beta-blockers, and calcium channel blockers to slow atrioventricular (AV) node conduction and decrease ventricular rate response. Antiarrhythmics from class I (eg, procainamide, flecainide, propafenone) and class III (eg, sotalol, amiodarone) converting to and maintaining sinus rhythm. anticoagulation using warfarin thromboembolic complication from chronic atrial arrhythmia Electrophysiologic ablation of atrial fibrillation or flutter circuits

Surgical options : open commissurotomy, - leaflet commissures are surgically split mitral valve replacement - with a metallic or a bioprosthetic valve indicated in patients when the valve morphology is unsuitable for PMV; moderate or severe mitral regurgitation ; thrombus present in the left atrium despite anticoagulation Mitral valve repair - if balloon valvotomy is not available • Surgical options include open commissurotomy, where the leaflet commissures are surgically split, and mitral valve replacement with a metallic or a bioprosthetic valve. Valve replacement is indicated in patients when the valve morphology is unsuitable for PMV, moderate or severe mitral regurgitation is present, or there is a thrombus present in the left atrium despite anticoagulation.

Surgical Intervention Surgical intervention is necessary when intervention is indicated and the valve is not amenable to balloon valvuloplasty. Mitral valvotomy Mitral valve replacement with mechanical valve or bioprosthesis Non pharmacologic intervention Consultations Consult a cardiologist and a cardiothoracic surgeon. Diet Salt intake should be restricted and excessive fluid intake minimized Activity avoid strenuous exertion. Increased heart rate may result in decreased diastolic filling, thereby decreasing cardiac output. Surgical Care Surgical intervention is necessary when intervention is indicated and the valve is not amenable to balloon valvuloplasty. Mitral valvotomy Commissurotomy consists of an incision of fused mitral valve commissures and shaving of thickened mitral valve leaflets. Fused chordae tendineae and papillary muscles can be divided to relieve subvalvular stenosis. Supravalvular tissue contributing to the MS should be resected. Mitral valve replacement with mechanical valve or bioprosthesis This is reserved for patients in whom mitral valvotomy is considered unlikely to achieve a satisfactory result. Mechanical mitral valve replacement is performed frequently in adolescents and adults in whom anticoagulation with warfarin (Coumadin) is not contraindicated. In older patients in whom warfarin therapy may be relatively contraindicated or in patients who have other contraindications to warfarin therapy, mitral valve replacement can be performed using a bioprosthesis, although these are less durable than mechanical prostheses. Weigh the risk of warfarin therapy against that of bioprosthetic valve deterioration resulting in the need for reoperation. Warfarin is contraindicated during pregnancy. Complications after mitral valve replacement include anticoagulation-related complications, valve thrombosis, valve dehiscence, infective endocarditis, valve malfunction, and embolic events. Consultations Consult a cardiologist and a cardiothoracic surgeon. Diet Salt intake should be restricted and excessive fluid intake minimized to avoid exacerbating signs and symptoms of CHF. Activity Patients with more severe than mild MS should avoid strenuous exertion. Increased heart rate may result in decreased diastolic filling, thereby decreasing cardiac output. Coexistent atrial arrhythmias result in loss of atrial augmentation of LV filling and may further impair cardiac output.

normal mitral valve area : 4 to 6 cm2. Initial intervention of choice: Percutaneous mitral balloon valvotomy. nonsurgical approach in which a balloon is inflated across the mitral valve to mechanically open the valve at the commissures of the leaflets Increases the mitral valve area and decreases the pressure gradient across the mitral valve. symptomatic patient with a valve area <1.5 cm2 or pulmonary hypertension ; symptomatic patients with moderate to severe MS and suitable valve morphology ; asymptomatic patients with moderate to severe MS associated with moderate to severe pulmonary hypertension and suitable valve morphology

Percutaneous mitral balloon valvuloplasty Indications CHF unresponsive to medical management asymptomatic patients with a pulmonary artery (PA) systolic pressure of 50 mm Hg or greater successful in 80-90% of selected cases. The procedural mortality rate is 1-2%