Valvular Heart Disease Asymptomatic 62 y/o male Long-standing heart murmur 2/6 SEM at base of heart PMI and carotid upstroke normal S2 splits normally ECG, CXR normal

Valvular Heart Disease What would you do at this time? Refer to cardiologist Order an echocardiogram Follow without further testing until symptoms develop

Is the Murmur Significant? Is the patient symptomatic? Are symptoms consistent with cardiac limitation? Is there chamber or cardiac enlargement on CXR or examination? Is there LVH or RVH on present ECG?

Clues from the Circulatory System Jugular venous pulse Carotid upstroke: brisk, delayed or weak? Peripheral pulses and pulse pressure Apical impulse: displaced, sustained or normal? Right ventricular lift Thrill Heart rate and rhythm

Innocent Cardiac Murmurs Midsystolic (never diastolic) A2 heard clearly Crescendo-decrescendo Variable intensity (grade 1-2/6) Does not radiate widely

Useful Maneurvers Valsalva: decreased venous return during Phase 2 Squat-Stand: Decreased venous return like Valsalva Sustained Hand Grip: increased SVR, increased cardiac output, increased BP

The Second Heart Sound Normal: Single S2 in expiration Wide: Right bundle branch block, RV pacing Fixed: ASD/common atrium Paradoxic: Left bundle branch block

Bedside Diagnosis of Pulmonary Hypertension P2 > A2 with P2 heard at LV apex Secondary findings of tricuspid insufficiency, elevated CVP, pedal edema Appropriate clinical situation: known CHF, severe lung disease, loud heart murmur, cardiac arrhythmia

Most Common Misdiagnosed Systolic Murmurs Mild Aortic Stenosis Mild Pulmonic Stenosis Atrial Septal Defect Mitral Valve Prolapse Hypertrophic Cardiomyopathy Question: Who warrants SBE prophylaxis?

SBE Prophylaxis-2007 Guidelines Prosthetic cardiac valve Previous infectious endocarditis Complex congenital heart disease Cardiac transplantation recipients who develop cardiac valvulopathy

Valvular Heart Disease Mild to Moderate Aortic Stenosis Yearly history and physical examination Focus on symptoms of angina, CHF, near syncope Echocardiogram q 3-5 years (peak velocity < 3 M/sec)

Valvular Heart Disease:Moderate to Severe Aortic Stenosis Annual history and physical examination Angina, CHF or near syncope? Echocardiogram yearly Peak velocity > 3 M/sec

Pulmonic Stenosis Congenital lesion with systolic ejection click Systolic ejection murmur at left upper sternal border Infraclavicular radiation Right ventricular lift

Atrial Septal Defects Primum ASD: Associated with cleft mitral valve and marked LAD on ECG Secundum ASD: Most common with female predominance Sinus venosus ASD: Associated with partial anomalous venous return All have wide/fixed split of S2

MVP: A Syndrome with Too Many Names Myxomatous mitral valve prolapse Click/murmur syndrome Floppy mitral valve syndrome “Classic” MVP Barlow’s Syndrome

History of Mitral Valve Prolapse 1962 Barlow describes MVP syndrome 1970 VPC’s and sudden cardiac death 1976 Prevalance 5-15%??? 1986 High risk markers for MVP complications identified 1989 Saddle shaped mitral annulus described

MVP: Clinical Exam Non-ejection click Mid-to-late systolic click Pansystolic murmur Mid-to-late systolic murmur Precordial “Honk” Changes with maneuvers “Silent” MVP

Complications of MVP Syndrome Ruptured chorda tendiniae Progressive mitral insufficiency Subacute bacterial endocarditis Sudden cardiac death Transient ischemic attacks

Complications in Classic and Nonclassic Mitral Valve Prolapse Classic (N=319) Nonclassic (N=137) P Value SBE 3.5% (11) <0.02 Severe MR 11.9% (30) <0.001 MV surgery 6.6% (21) 0.7% (1) TIA/stroke 7.5% (24) 5.8% (8) ns

Hypertrophic Cardiomyopathy May occur with or without dynamic LVOT obstruction Systolic ejection murmur at lower left sternal border Murmur increases during Phase 2 of Valsalva Bisferiens pulse

Hypertrophic Cardiomyopathy Treatment: General Guidelines Physical Activity: Avoid strenuous activity (no competitive sports), avoid dehydration Endocarditis Risk: Dental care Genetic Counseling: Screen first degree relatives, pregnancy counseling

Hypertrophic Cardiomyopathy: Treatment General guidelines Medical therapy: Beta blockers, Ca channel blockers Catheter based septal ablation Surgical myectomy AICD implantation

HCM: ECG from 1995

HCM: ECG from 2002

HCM: ECG from January 2010

Is the Murmur Significant? Is the patient symptomatic? Are symptoms consistent with cardiac limitation? Is there cardiac enlargement or chamber enlargement on CXR or exam? Is there LVH or RVH on ECG?