1. 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

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

3. 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?

4. 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

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

6. 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

7. 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

8. 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

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

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

12. 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)

13. 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

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

16. 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

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

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

20. 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

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

23. 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

24. 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

25. 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

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

27. HCM: ECG from 1995

28. HCM: ECG from 2002

29. HCM: ECG from January 2010

30. 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?