Valvulopathies
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Mitral Stenosis
I. Symptoms
a. Symptoms of LHF
b. Pulmonary hypertension
II. General signs
a. Mitral facies (rosy cheeks with bluish tinge)
b. Peripheral cyanosis
III. Pulse and BP
a. Reduced to decreased CO
b. AF may present due to left atrial enlargement
IV. Palpation
a. Tapping apex beat
b. If Pulmonary HT
i. Palpable P2
ii. Parasternal heave
V. Auscultation
a. Low-pitched rumbling diastolic murmur over apex Best heard with bell
and patient in left lateral position
b. Severe MS Diastolic thrill over apex
Causes
Rheumatic
Mitral regurgitation (chronic)
I. Symptoms
a. Dyspnoea, fatigue
II. General
a. Tachypnoea
III. Pulse
a. AF relatively common
IV. Palpitation
a. Apex beat displaced, diffuse and
hyperdynamic (dilation)
b. Pansystolic thrill (Grade 4+)
V. Auscultation
a. Soft or absent S1
i. By the end of diastole, atrial and ventricular pressures have equalised
and the valve cusps have drifted back together
b. LV S3 (volume loaded)
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c. Pansystolic murmur, maximal at apex radiating to axilla
d. Mid-systolic click may be heard if MVP
Severe MR can lead to LVF and pulmonary hypertension
Causes (chronic)
1. Rheumatic
2. MVP
3. Cardiomyopathy (hypertrophic, dilated, restrictive)
4. Connective tissue disease Marfan’s, RA
Causes (acute)
1. MI (rupture of papillary muscles)
2. Infective endocarditis!
Aortic stenosis
I. Symptoms
a. Exertional chest pain, exertional dyspnoea, exertional syncope
II. Pulse
a. Plateau
III. Palpation
a. Apex beat hyperdynamic and may be displaced Left ventricular
hypertrophy
b. Systolic thrill
IV. Auscultation
a. Mid-systolic ejection murmur, maximal over aortic area and radiating into the
carotids (may be heard widely over precordium)
b. Murmur loudest with patient sitting up and in full expiration
Severe AS
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Causes of AS
1. Degenerative calcific AS
2. Rheumatic
Aortic regurgitation
I. Symptoms
a. Exertional dyspnoea, fatigue, exertional chest pain
II. General signs
a. Marfan’s syndrome, Ankylosing
spondylitis
III. Pulse and BP
a. Pulse Collapsing, water-hammer
b. Wide pulse pressure (not in acute form)
c. Bisferiens pulse (double) if severe AR, at
carotids
IV. Neck
a. Prominent carotid pulsations (Corrigan’s
sign)
V. Palpation
a. Apex beat displaced and hyperkinetic
b. Diastolic thrill (patient sits up and
breathes out)
VI. Auscultation
a. Decrescendo high-pitched diastolic murmur beginning immediately after the
second heart sound, loudest and 3rd/4th ICS due to radiation
b. ESM present if associated AS
c. Austin Flint murmur Low-pitched rumbling mid-diastolic murmur
Severe AR
Collapsing pulse
Wide pulse pressure >/= 80
LV S3
Signs of LVF
Causes
Chronic AR Acute AR
1. Rheumatic 1. Infective endocarditis
2. Congenital 2. Marfan’s Dissecting aneurysm
3. RA, Ankylosing spondylitis
4. Marfan’s syndrome
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Tricuspid stenosis
Very rare
I. JVP
a. Raised
II. Auscultation
a. Diastolic murmur similar to MR but maximal over left sternal edge and
increased with inspiration, won’t radiate to axilla
III. Liver
a. Presystolic pulsation
IV. Causes
a. Rheumatic heart disease
Tricuspid regurgitation
I. JVP
a. Elevated if RVF has occurred
II. Palpation
a. Parasternal heave
III. Auscultation
a. Pansystolic murmur, maximal at tricuspid area, increases with inspiration
IV. Abdomen (NB)
a. Liver Pulsatile, large and tender
b. Ascites, oedema and pleural effusion may also be present
Causes
1. RVF
2. RHD, usually with mitral valve disease
3. Infective endocarditis
4. Congenital with Ebstein’s anomaly
Read up about Pulmonary Stenosis and Pulmonary Regurgitation in Tally (pg. 108) as it is
very uncommon
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