Tuesday, October 11, 2016

Heart Murmurs and Valvular Heart Disease

Heart Murmurs/Valvular Heart Disease*
  • Most common causes of mitral/aortic valve disorders are congenital defects; other causes include rheumatic heart disease, connective tissue disorders, infection, sensile conditions
  • Most common presenting symptoms: dyspnea, fatigue, decreased exercise tolerance
    • Other: Cough, rales, paroxysmal nocturnal dyspnea or hemoptysis, hoarseness
    • Physical exam - heart murmur +/- palpable thrill  
  • Diagnostic Studies
    • EKG - not useful for specific diagnosis → shows chamber hypertrophy
    • CXR
      • Aortic → left sided atrial enlargement, ventricular hypertrophy
      • Mitral → atrial enlargement only
    • Echo (transesophageal) and cardiac cath → definitive
  • Treatment
    • Surgical repair or replacement of defective valve
    • Good exercise tolerance → diuretics and vasodilators for pulmonary congestion and digoxin or BB for dysrhythmias
    • Anticoagulant therapy for thromboemboli prophylaxis
    • Antibiotics to prevent endocarditis and recurrent rheumatic fever


Mitral Valve Prolapse

Regurgitant flow across mitral valve
Decreased left ventricular volume results in earlier prolapse and click heard earlier in systole, closer to S1

Increased left ventricular volume results in delayed prolapse, click heard later in systole

Thin females with minor chest wall deformities

Associated: Ehlers-Danlos, Marfan Syndrome, Mitral Regurgitation
1. Mid-systolic click
2. Followed by a mid-to-late systolic murmur (mitral regurgitation)
3. Loud S2

“Click” is caused by prolapse of leaflets into left atrium and tensing of mitral valve apparatus
1. Maneuvers that increase left ventricular end diastolic volume (preload)/worsen: seated/standing → squatting
2. Maneuvers causing delay in prolapse: handgrip, standing from seated position, valsalva


Health Maintenance
1. Leads to mitral regurgitation
2. Predisposed to infective endocarditis
3. ADA no longer recommends prophylactic antibiotics for MVP