ABB MD FACC © 1 Heart Valves & Cardiac Auscultation A. Bornstein, M.D., F.A.C.C. Assistant Professor of Science Education Hofstra North Shore-LIJ School of Medicine Hempstead, NY

ABB MD FACC © Cardiac Murmurs Auscultatory sound: cardiac or vascular origin of short duration Auscultatory sound: cardiac or vascular origin of short duration Cardiac murmurs are audible turbulent sound waves in the range of ,000 cycles/second; often, first sign of underlying valvular pathology Cardiac murmurs are audible turbulent sound waves in the range of ,000 cycles/second; often, first sign of underlying valvular pathology May be systolic or diastolic, pathological or benign May be systolic or diastolic, pathological or benign Systolic murmurs may be due to physiological increases in blood flow velocity or might indicate an as yet asymptomatic cardiac disease Systolic murmurs may be due to physiological increases in blood flow velocity or might indicate an as yet asymptomatic cardiac disease Diastolic murmurs and most continuous murmurs are almost always pathological and require further evaluation Diastolic murmurs and most continuous murmurs are almost always pathological and require further evaluation ECG & CXR provide some limited diagnostic information and are readily available tests ECG & CXR provide some limited diagnostic information and are readily available tests 2

ABB MD FACC © Characteristics of Murmurs Benign murmur:Benign murmur: -Early to mid peaking systolic -Soft (I-II/VI) -Varies with respiration -Presents during normal exam and work-up Pathologic murmur:Pathologic murmur: -All diastolic murmurs -All pansystolic murmurs (holosystolic murmurs) -Late peaking systolic murmurs -Very loud murmurs (III-V/VI) -Continuous murmurs 3

ABB MD FACC © Grading of Heart Murmurs Grade I-Grade VI 4

ABB MD FACC © Turbulent Flow vs. Laminar Flow Normally, blood flow is laminar; with  flow velocity across valve or  valve orifice (stenosis), laminar flow is disrupted  turbulence  murmur; blood does not flow linearly & smoothly in adjacent layers; instead flow becomes chaoticNormally, blood flow is laminar; with  flow velocity across valve or  valve orifice (stenosis), laminar flow is disrupted  turbulence  murmur; blood does not flow linearly & smoothly in adjacent layers; instead flow becomes chaotic Turbulence:  energy needed to drive blood flow because turbulence  loss of energy as friction, (generates heat); when plotting a pressure-flow relationship, turbulence  perfusion pressure needed to drive a given flow; at any given perfusion pressure, turbulence leads to  in flowTurbulence:  energy needed to drive blood flow because turbulence  loss of energy as friction, (generates heat); when plotting a pressure-flow relationship, turbulence  perfusion pressure needed to drive a given flow; at any given perfusion pressure, turbulence leads to  in flow Magnitude of perfusion pressure gradient depends on severity of valve stenosis and flow rate or flow velocityMagnitude of perfusion pressure gradient depends on severity of valve stenosis and flow rate or flow velocity V = Q/t Q = A V

ABB MD FACC © Velocity & Flow Continuity equation is valid for any incompressible fluid. The consequences are when water flows from a hose into a narrow spray nozzle, it emerges with a large speed; that is the purpose of the nozzle. Conversely, when a river empties into 1 end of a reservoir, the water slows, picking up speed again when it leaves the other end of the reservoir. Continuity equation is valid for any incompressible fluid. The consequences are when water flows from a hose into a narrow spray nozzle, it emerges with a large speed; that is the purpose of the nozzle. Conversely, when a river empties into 1 end of a reservoir, the water slows, picking up speed again when it leaves the other end of the reservoir. Speed increases when cross-sectional area decreases Speed increases when cross-sectional area decreases Speed decreases when cross-sectional area increases Speed decreases when cross-sectional area increases When a tube narrows, the same volume occupies a greater length. For the same volume to pass points 1 & 2 in a given time, the speed must be greater at point 2. The process is exactly reversible. If the fluid flows in the opposite direction, its speed will decrease when the tube widens. (Note, relative volumes of 2 cylinders &corresponding velocity vector arrows are not drawn to scale) When a tube narrows, the same volume occupies a greater length. For the same volume to pass points 1 & 2 in a given time, the speed must be greater at point 2. The process is exactly reversible. If the fluid flows in the opposite direction, its speed will decrease when the tube widens. (Note, relative volumes of 2 cylinders &corresponding velocity vector arrows are not drawn to scale)

ABB MD FACC © Continuity Equation Severity of stenosis Jet velocity (m/s) Mean gradient (mm Hg) Area (cm 2 ) Mild<325>1.5 Moderate Severe>440<1

ABB MD FACC © Turbulent Flow vs. Laminar Flow Normally, blood flow is laminar; with  flow across valve or  valve orifice (stenosis), laminar flow is disrupted  turbulence  murmur; blood does not flow linearly & smoothly in adjacent layers; instead flow becomes chaoticNormally, blood flow is laminar; with  flow across valve or  valve orifice (stenosis), laminar flow is disrupted  turbulence  murmur; blood does not flow linearly & smoothly in adjacent layers; instead flow becomes chaotic Turbulence:  energy needed to drive blood flow because turbulence  loss of energy as friction, (generates heat); when plotting a pressure-flow relationship, turbulence  perfusion pressure needed to drive a given flow; at any given perfusion pressure, turbulence leads to  in flowTurbulence:  energy needed to drive blood flow because turbulence  loss of energy as friction, (generates heat); when plotting a pressure-flow relationship, turbulence  perfusion pressure needed to drive a given flow; at any given perfusion pressure, turbulence leads to  in flow Magnitude of perfusion pressure gradient depends on severity of valve stenosis and flow rate or flow velocityMagnitude of perfusion pressure gradient depends on severity of valve stenosis and flow rate or flow velocity

ABB MD FACC © Thoracic Landmarks

ABB MD FACC © Thoracic Landmarks

ABB MD FACC © Cardiac Timing Cycles

ABB MD FACC © Examples of Murmurs Benign: Benign: —Flow murmur Pathologic: Pathologic: —Diastolic murmur: MS; TS; AI; PI —Pansystolic (holosystolic) murmur: MR; TR; VSD —Loud murmurs: > III/VI —Continuous murmur: patent ductus arteriosus (PDA) 12

ABB MD FACC © Phonocardiograms From Normal & Abnormal Heart Sounds

ABB MD FACC © Murmurs, Extra Sounds, and Cardiac Auscultation Timing Cycles

ABB MD FACC © Timing Auscultatory Events by Carotid Artery & Jugular Venous Pulse

ABB MD FACC © Murmurs by Position: Systolic Murmurs Right upper sternal border (RUSB)Right upper sternal border (RUSB) -Aortic stenosis (AS) Left upper sternal border (LUSB)Left upper sternal border (LUSB) -Pulmonary insufficiency (PI) Left lower sternal border (LLSB)Left lower sternal border (LLSB) -Tricuspid regurgitation (TR) -Ventricular septal defect (VSD) -Hypertrophic cardiomyopathy (HCM) ApexApex -Mitral regurgitation (MR) 16

ABB MD FACC © Murmurs by Position: Diastolic Murmurs Left upper sternal border (LUSB) Left upper sternal border (LUSB) –Pulmonary insufficiency (PI) Left lower sternal border (LLSB) Left lower sternal border (LLSB) –Tricuspid stenosis (TS) Apex Apex –Mitral stenosis (MS) 3 rd intercostal space (ICS), lower sternal border (LSB) 3 rd intercostal space (ICS), lower sternal border (LSB) –Aortic Insufficiency (AI) 17

ABB MD FACC © Continuous Murmurs Require continuous pressure gradient for continuous blood flow Require continuous pressure gradient for continuous blood flow Occurs at artery-vein connections Occurs at artery-vein connections –Patent ductus arteriosus (PDA) –Arteriovenous malformation (AVM) –Venous hum 18

ABB MD FACC © Aortic Stenosis Aortic area

ABB MD FACC © Aortic Stenosis 20 Degenerative calcific aortic stenosis Congenital aortic stenosis (unicuspid valve) Congenital aortic stenosis (bicuspid valve) Normal aortic valve

ABB MD FACC © Aortic Flow Murmur vs. Aortic Stenosis Normal aortic valve with flow murmur Stenotic aortic valve with pathologic murmur

ABB MD FACC © Summary of Systolic Murmurs

ABB MD FACC © Summary of Diastolic Murmurs

ABB MD FACC © Pulse Characteristics: Normal & Aortic Valve Disease Pulse Characteristics: Normal & Aortic Valve Disease 3) Aortic insufficiency 2) Aortic stenosis 1) Normal Carotid pulse Brachial pulse: combined AS & AR

ABB MD FACC © Valve Lesions & Hemodynamics (Aortic Stenosis) Normal pressures Aortic stenosis

ABB MD FACC © Aortic Stenosis & Murmur Murmurs of aortic stenosis Aortic stenosis

ABB MD FACC © Aortic Stenosis & Murmur Murmurs of aortic stenosis Aortic stenosis hemodynamics

ABB MD FACC © 28 Early Ejection Click & Systolic Ejection Murmur Stenotic bicuspid aortic valve with ejection click

ABB MD FACC © 29 Systolic Ejection Murmur: Severe Aortic Stenosis Aortic pressure LV pressure Aortic stenosis is most often diagnosed while still asymptomaticAortic stenosis is most often diagnosed while still asymptomatic Systolic crescendo-decrescendo murmur is audible at the RUSB, radiating to carotid arteriesSystolic crescendo-decrescendo murmur is audible at the RUSB, radiating to carotid arteries Pressure differentials between LV & aorta, obtained at catheterization, pathognomonic for ASPressure differentials between LV & aorta, obtained at catheterization, pathognomonic for AS Transvalvular gradient

ABB MD FACC © Critical Aortic Stenosis: Transvalvular Gradient LA LV Aorta Apex ES MSM S1S1S1S1 S2S2S2S2 LVEDP Transvalvular gradient

ABB MD FACC © Critical Aortic Stenosis: Transvalvular Gradient

ABB MD FACC © Bicuspid Aortic Valve With Aortic Regurgitation (Tricuspid) rheumatic or degenerative aortic valve Congenital bicuspid aortic valve

ABB MD FACC © Valve Lesions & Hemodynamics (AR) Normal pressures Aortic regurgitation

ABB MD FACC © Aortic Regurgitation Hemodynamics Aortic regurgitation on MRA Upsloping LV diastolic pressure Wide pulse pressure

ABB MD FACC © Acute Versus Chronic Aortic Regurgitation

ABB MD FACC © Mitral Regurgitation

ABB MD FACC © Overall Causes of Mitral Regurgitation

ABB MD FACC © Causes of Mitral Insufficiency

ABB MD FACC © Causes of Severe Mitral Regurgitation MV leaflet perforation Papillary muscle infarct mitral annular calcification Billowing mitral leaflets (MVP)

ABB MD FACC © Mitral Stenosis & Regurgitation

ABB MD FACC © Myxomatous MVP: Forms of Mitral Regurgitation

ABB MD FACC © Valve Lesions & Hemodynamics (MR) Normal pressures Mitral regurgitation

ABB MD FACC © Acute Versus Chronic Mitral Regurgitation

ABB MD FACC © Carotid Pulse & Cardiac Auscultation in Critical AS versus Acute MR 1) Critical aortic stenosis 2) Acute mitral regurgitation AS or Acute MR??

ABB MD FACC © Summary of Systolic Murmurs

ABB MD FACC © Mitral Stenosis Aortic pressure LV pressure LVDM pressure Mitral stenosis

ABB MD FACC © Mitral Stenosis

ABB MD FACC © Critical Mitral Stenosis Mitral stenosis chest X-ray: P-A view Mitral stenosis: superior view Rheumatic heart disease with mitral stenosis

ABB MD FACC © Severe Longstanding Mitral Stenosis Mitral stenosis in the parasternal long axis Mitral stenosis in the apical 4 chamber view Normal mitral in the parasternal long axis Normal mitral in the apical 4 chamber view

ABB MD FACC © Valve Lesions & Hemodynamics (Mitral Stenosis) Normal pressures Mitral stenosis

ABB MD FACC © Normal MV Function vs. Mitral Stenosis

ABB MD FACC © Mitral Stenosis Pre balloon angioplasty Post balloon angioplasty

ABB MD FACC © Summary of Diastolic Murmurs

ABB MD FACC © Percutaneous Aortic Valve Implantation

ABB MD FACC © Percutaneous Aortic Valve Implantation

ABB MD FACC © Mitral regurgitation Mitral stenosis Aortic regurgitation Aortic Stenosis

ABB MD FACC © Aortic Stenosis & Murmur Murmurs of aortic stenosis Aortic stenosis