Heart Murmurs &
Valvular Heart Disease
Victor Politi, M.D., FACP
Medical Director, SVCMC,
School of Allied Health
Professions, Physician
Assistant Program
What is a Heart Murmur?
A sound produced as blood flows through
the chambers and large blood vessels of
the heart during the cardiac cycle of
contraction and relaxation.
What is a Heart Murmur?
The heart beat normally makes two
sounds:
the first is Lub and the second is Dub, these
two sounds follow each other (Lub Dub) and
are not separated by any extra sounds.
What is a Heart Murmur?
A heart murmur will be heard as a
swishing or a whistling sound in addition
to the normal Lub-Dub sound.
The moving blood sounds like running
water in a garden hose.
What is a Heart Murmur?
A heart murmur is not a diagnosis or
disease, it is a sign to alert our attention
to check if there is anything wrong.
Heart murmurs come in different sounds
which may help indicate whether the
murmur is normal or abnormal.
What is a Heart Murmur?
Some murmurs are benign or harmless
and are more of a finding than a
condition.
A benign murmur is not associated with
any significant underlying abnormality of
the heart or its vessels.
What is a Heart Murmur?
Many young people can have
benign/innocent flow murmurs and still
have normal cardiac structure and
function.
What causes a heart murmur?
Innocent/Benign Murmur Causes:
Anemia
Fever
Venous Hum
a common innocent murmur heard during
childhood. This murmur is heard as a soft
humming sound at the base of the neck just
above the collarbone. It results from the normal
blood flow in the large neck veins (jugular veins).
Innocent/benign Causes:
Venous Hum
Light compression of the neck vein will
make the murmur transiently disappear, or
the murmur will sound louder when
turning the child's head to one side or
another.
These simple maneuvers help differentiate
a Venous Hum from the murmurs
resulting from heart disease.
Innocent/benign Causes:
Still’s Murmur
 This heart murmur is named after the doctor who
described it.
 It is heard most frequently in active, healthy 3 to 7-year
old children.
 The murmur represents the normal sound of blood
gushing out into the aorta during heart contraction.
 It has a musical tone to it and thus is frequently
described as "musical murmur"; it usually sounds softer
during sitting and may sound very loud during fever,
anxiety, or exercise.
Still’s Murmur
Pathologic Murmur
A pathologic heart murmur is one
associated with a structural or functional
abnormality of the heart.
Pathologic Murmurs
Narrow Valve- stenosis
Valve insufficiency/regurgitation
Septal defects- Hole in the Heart
Valve
insufficiency/regurgitation
As the heart valve closes some blood leaks back
making a blowing sound.
A leaking valve is called insufficient or
regurgitating.
Its importance depends on how much blood is
leaking, what valve is involved, and how long it
has been going on.
Septal defects – hole in heart
If the pressure in the heart chambers is not the
same, the blood will flow from the high to the lowpressure chamber, producing a murmur sounding like
a waterfall.
If the hole is small, it will make a very loud sound.
If the hole is large it may make a faint murmur that
may go unnoticed for some time; therefore a faint
murmur may sometimes indicate a serious problem.
Septal defects – hole in heart
If it is between the upper cardiac
chambers, it is called Atrial Septal Defect
(ASD), and is called Ventricular Septal
Defect (VSD) if it is between the lower
cardiac chambers.
The importance of septal defects depends
on their size and site.
Mechanisms of Heart
Murmurs
Most murmurs are produced as blood
flows past the cardiac valves, which
separate the chambers of the heart, or
through the valves that lead to the great
vessels of the lungs and the systemic
circulation.
Mechanisms of Heart
Murmurs
They are usually caused by one of the following
mechanisms:
Flow across partial obstruction (e.g. aortic stenosis)
Flow across valvular or intravascular irregularity w/o
obstruction (e.g. bicuspid aortic valve w/o true
stenosis)
Increased flow through normal structures (e.g. aortic
systolic murmur associated w/anemia)
Mechanisms of Heart
Murmurs
Flow into dilated chamber (e.g. aortic systolic
murmur associated w/aneurysmal dilatation
of the ascending aorta)
Backward or regurgitant flow across an
incompetent valve or defect (e.g. mitral
regurgitation)
Shunting of blood out of a high pressure
chamber or artery through abnormal passage
(e.g. ventricular septal defect)
Midsystolic Ejection Murmurs
Most common type of murmur
May be:
1. Organic
(i.e. secondary to structural cardiovascular abnormality)
2. Functional
(i.e. secondary to a physiologic alteration w/or w/o heart
dx)
3. Innocent
(i.e. not associated with any functional or structural
abnormality)
Midsystolic Ejection Murmurs
Organic causes include:
Aortic stenosis
Pulmonoic stenosis
Pansystolic Regurgitant
Murmurs
Heard when blood flows from a chamber
of high pressure to one of lower pressure
through a valve or other structure that
should be closed.
Regurgitation (incompetence or
insufficiency) means there is a leak!
Pansystolic Regurgitant
Murmurs
The murmur begins immediately with the
1st heart sound and continues up to the
2nd heart sound.
Causes include:
Mitral regurgitation LV LA
Tricuspid regurgitation RV
RA
Ventricular septal defect LV RV
Diastolic Murmurs
Unlike systolic murmurs, diastolic murmurs are
almost always indicative of heart disease.
Two general types may be distinguished:
The diastolic rumble originating in atrioventricular
valves
The early diastolic murmurs of semilunar valve
incompetence
Diastolic Murmurs
Diastolic rumbling murmurs are caused
by:
Flow across distorted or stenotic mitral or
tricuspid valves
Increased blood flow across normal mitral or
tricuspid valves
Diastolic Murmurs
Because these valves open only after the
aortic and pulmonic valves close, a short
period of silence separates S2 from the
beginning of diastolic rumbles.
These murmurs are low in pitch, rumbling
in quality, and heard best with the bell of
the stethoscope in light skin contact.
Diastolic Murmurs
Semilunar valve incompetence may result
either from valvular deformity or from
dilatation of the valvular ring.
In either case blood regurgitates from the
great vessel back into the ventricle.
Diastolic Murmurs
Murmurs of aortic regurgitation, together with
most murmurs of pulmonic regurgitation, start
immediately after the second sound and then
diminish in intensity
In contrast to the rumbling atrioventricular valve
murmurs, they are high pitched and blowing
and best heard with the diaphragm pressed
firmly on the chest.
Diastolic Murmurs
The most common examples of these two
types of diastolic murmurs are:
Mitral stenosis
Aortic regurgitation
Points to Remember !
 If the flow is excessive or turbulent, a murmur may be
manifest.
 Blood flowing through a tight valve will produce a
murmur.
 Blood that is leaking back across an improperly sealing
valve also can cause a murmur.
 Occasionally, abnormal communications (holes) between
chambers of the heart can result in the presence of a
murmur.
Diagnosing a Murmur
Diagnosing a heart murmur begins with
auscultation of the heart.
The location, quality, pitch and variation in
the sound are all important clues to
whether the murmur is benign or
pathologic.
Murmur Evaluation
One of the most useful tests in evaluating
a murmur is an echocardiogram.
Other tests –
EKG
Chest x-ray
Valvular Heart Disease
90% of valvular disease is chronic, with
decades between the onset of the
structural abnormality and symptoms
The four heart valves prevent retrograde
flow of blood during the cardiac cycle,
allowing efficient ejection of blood with
each contraction of the cardiac chambers
The mitral valve has two cusps, while the
other three heart valves normally have
three cusps
The right and left papillary muscles
promote effective closure of the tricuspid
and mitral valves, respectively.
Valvular Heart Disease
Mitral Stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Tricuspid Stenosis
Tricuspid Regurgitation
Mitral Stenosis
Mitral StenosisPathophysiology
Despite its declining frequency, rheumatic
heart disease is still the most common
cause of mitral valve stenosis
Due to progressive dilation of the atria,
many patients with mitral stenosis will go
on to develop atrial fibrillation
Mitral Stenosis
Normal mitral valve 4-6cm2
When the valve narrows <1.5cm2, left
atrial pressure must rise to maintain
normal flow across the valve and a normal
cardiac output
This results in a pressure difference
between the left atrium and the left
ventricle during diastole
Mitral Stenosis
In mild cases of mitral stenosis, the
patient may be asymptomatic and cardiac
output and left atrial pressure may be
normal
In moderate cases (valve area < 1.5cm2)
as left atrial pressure rises - dyspnea and
fatigue appear
Mitral Stenosis
With severe stenosis, pulmonary venous
congestion at rest and reduced cardiac
output occur resulting in dyspnea, fatigue,
and right sided heart failure
Mitral Stenosis Clinical Findings
Dyspnea
In 80% of cases, most common presenting
symptom
Paroxysmal nocturnal dyspnea
hemoptysis
2nd most common symptom
Orthopnea
Symptoms often precipitated by onset of
pregnancy or atrial fibrillation
Mitral Stenosis Clinical Findings
Murmur
duration varies - severity of stenosis & heart
rate
middiastolic rumble, crescendos into S2
Heart Sounds
long snapping S1
apical impulse is small and tapping due to
underfilled left ventricle
Mitral Stenosis - Murmur
The pressure gradient and the length of
the diastolic murmur reflect the severity of
mitral stenosis
Mitral Stenosis
Diagnostic Studies
Echocardiography
reveals thickened valve that opens poorly,
closes slowly
rather than moving in opposite directions,
the anterior and posterior leaflets are fixed,
moving together
rule out atrial myxoma (clinical presentation
similar to mitral stenosis)
left atrial size can be accurately measured
increased size - increased risk of atrial fibrillation
Mitral Stenosis Diagnostic Studies
ECG
may show notched or diphasic P waves and
right axis deviation
X-ray
early finding- straightening of left heart
border (left atrial enlargement)
subsequent findings - pulmonary congestion,
redistribution of flow to upper lung fields,
Kerley B lines, along with an increase in
vascular markings
Kerley B lines are short, horizontal linear radiopacities at the periphery
of the lung that represent thickened, interlobular septa
Mitral Stenosis Treatment
Warfarin anticoagulation - after A-Fib
Surgery - indications
uncontrolled pulmonary edema
limiting dyspnea & intermittent pulmonary edema
pulmonary HTN w/right ventricular hypertrophy or
hemoptysis
limitation of activity despite ventricular rate
control/medical therapy
recurrent systemic embolic despite anticoagulation
w/moderate-severe stenosis
Mitral Stenosis
Treatment
Open mitral commissurotomy
patients w/o substantial mitral regurgitation
Valve replacement surgery
indicated when combined stenosis and
insufficiency are present or when the mitral
valve is so distorted and calcified that a
satisfactory valvulotomy is impossible
Mitral Stenosis
Prosthetic valves
Warfarin anticoagulant therapy required usually for at least initial 3 months with
bioprosthesis - if atrial fibrillation persists anticoagulation therapy should continue
possible problems
thrombosis
paravalvular leak
endocarditis
degenerative changes in tissue valves
Mitral Stenosis
Treatment
Balloon valvuloplasty
effective in patients w/o mitral regurgitation
and in cases where valve calcification is not
excessive
Mitral Regurgitation
(Mitral Insufficiency)
(Mitral Incompetence)
Mitral Regurgitation
The mitral leaflets do not close normally
during left ventricular systole, blood is
ejected into the left atrium as well as
through the aortic valve
this results in increased volume load on
the left atria
Mitral Regurgitation
Mitral Regurgitation leads to left atrial
enlargement - subsequently resulting in
atrial fibrillation
Mitral Regurgitation
Case presentation varies depending upon
the speed with which the condition
develops
In acute cases, left atrial pressure
elevates abruptly
can result in pulmonary edema if severe
Mitral Regurgitation
Acute cases
Typically, patient presents with dyspnea,
tachycardia, and pulmonary edema
ECG-may show evidence of acute inferior
wall infarction (more common than anterior
wall)
absent to minor calcification of mitral valve
no stenosis, little left ventricle dilation
X-ray-minimally enlarged left atrium,
pulmonary edema - from papillary muscle
Mitral Regurgitation
In chronic cases, the left atrium dilates, left
atrial pressure rises little, even with large
regurgitant flow
slowly progressive- years to decades
exertional dyspnea (1st symptom), and fatigue that
progress gradually over years
pressure in the pulmonary veins show a transient
rise during exercise
ECG-may demonstrate LVH
x-ray-left ventricular/atrial enlargement in
Mitral Regurgitation
Intermittent cases
typically present with acute episodes of
respiratory distress due to pulmonary edema
can be asymptomatic between attacks
Mitral Regurgitation
Many causes rheumatic disease
myxomatous degeneration (mitral valve
prolapse)
connective tissue disease (Marfan's
syndrome)
infective endocarditis
cardiac tumors (myxoma) - rare cause
Mitral Regurgitation
Nonrheumatic mitral regurgitation may
develop suddenly after MI,valve
perforation in infective endocarditis, or
ruptured chordae tendineae in MVP
Inferior MI due to right coronary occlusion
is the most common cause of ischemic
mitral valve incompetence
Mitral Regurgitation
Rheumatic heart disease is the most
common cause of chronic mitral
incompetence
Mitral Regurgitation
Appetite suppressant drugs (fenfluramine
and phentermine, or dexfenfluramine)
have been associated with cardiac valve
incompetence
Mitral Regurgitation
Murmur
Acute; harsh apical systolic murmur, begins
with S1, may end before S2
Heart Sounds
S1 and S2 are heard
Mitral Regurgitation Diagnostic Studies
Echocardiography
TEE
Nuclear Medicine/MRI
Cardiac Cath
MVP
Click-murmur syndrome
Etiology unknown - possibly congenital
Usually asymptomatic
May be associated with
nonspecific chest pain
dyspnea
fatigue
palpitations
MVP
Characteristic midsystolic click
may be multiple, often followed by late
systolic murmur
accentuated in standing position
Most commonly affects women
10% of cases - healthy young women
many thin
some with minor chest wall deformities
MVP
Usually no sequelae if only midsystolic
click present
significant mitral regurgitation may
develop in cases with late or pansystolic
murmur (due to rupture of chordae
tendineae)
MVP
Need for valve replacement
increases with age
men more than women require surgery
2% of patients over age 60 with significant
regurgitation require surgery
To reduce risk of endocarditis - antibiotic
prophylaxis prior to dental work or
surgery
MVP
Aggressive management necessary in
cases of symptomatic ventricular
tachycardia
Diagnosis primarily clinical - can be
confirmed by echocardiogram
MVP
With MVP there is an increased incidence
of sudden death
dysrhythmias
TIA for persons under age 45
MVP
In cases of MVP w/o mitral regurgitation
at rest, exercise provokes mitral
regurgitation in 32% of patients
this is a predictor for a high risk of morbid
events
Mitral regurgitation due to papillary
muscle dysfunction/MI
Mitral regurgitation may subside as left
ventricular dilatation diminishes or the
infarction heals
Transient (sometimes severe)
regurgitation may occur after an MI
In cases of persistent severe
regurgitation, poor prognosis with or w/o
surgery
Secondary Mitral Regurgitation
Papillary muscle dysfunction or dilation of
the mitral annulus in patients with dilated
cardiomyopathy of any origin
Valve replacement generally
contraindicated due to poor risk:benefit
ratio
However, valve replacement in cases
where the Left EF >30% have shown
good result in some studies
Aortic Stenosis
Aortic Stenosis
Blood flow into the aorta is obstructed,
producing progressive LVH and low
cardiac output
Most commonly, this is caused by
progressive valvular calcification
In younger patients with congenital bicuspid
valve
In the elderly with normal three-cusp valves
Aortic Stenosis
In the elderly the aortic valve becomes
increasingly sclerotic and eventually
stenotic
Degenerative valve disease is three -four
times more frequent in men than women
More common in smokers and
hypertensives
Aortic Stenosis
Congenital heart disease most common cause
Rheumatic heart disease second most common cause
degenerative heart disease (calcific aortic
stenosis)
3rd most common cause overall
Most common cause > age 70
Aortic Stenosis
Treatment
surgery is indicated in all symptomatic
patients
exceptions declining left ventricular function
very severe left ventricular hypertrophy
very high gradients
severely reduced valve areas
Aortic Stenosis
Anticoagulation with warfarin is required
for mechanical prostheses but not
essential with bioprosthesis
bioprosthetic valves undergo degenerative
changes and usually require replacement
with 7-10 years - newer ones may be
more resilient
Aortic Stenosis
Ross procedure
switching the patient’s pulmonary valve to
the aortic position, placing a bioprosthesis in
the pulmonary position
(bioprosthesis do not deteriorate as fast on
the right side of the heart)
This procedure has produced excellent
results without anticoagulation
Aortic Stenosis
Percutaneous balloon valvuloplasty
short term reduction in severity
restenosis recurs rapidly in most adults with
calcified valves
used on poor candidates for surgery or to
stabilize high risk patients prior to surgery
Aortic Stenosis
Classic triad of symptoms
dyspnea
chest pain
syncope
Aortic Stenosis
Dyspnea is usually the first symptom,
followed by paroxysmal nocturnal
dyspnea, syncope on exertion, angina,
and MI
Aortic Stenosis
Sudden death, usually from a
dysrhythmia, occurs in 25% of cases
x-ray- early on - normal, eventually LVH
and findings of CHF are evident if the
valve is not replaced
ECG-demonstrates criteria for LVH, left or
right bundle branch block is also present
in 10% of cases
Aortic Stenosis
Murmur harsh systolic ejection murmur
Heart sounds
paradoxic splitting of S2, S3, and S4 may be
present; pulse of small amplitude; pulse has a
slow rise and sustained peak
Aortic Regurgitation
(Chronic Regurgitation)
(Aortic Incompetence)
Aortic Regurgitation
20% of cases acute in nature
Infective endocarditis - accounts for
majority of cases
aortic dissection at the aortic root causes
the remainder of cases
Aortic Regurgitation
In acute cases, sudden increase in
backflow of blood into the ventricle raises
left ventricular end diastolic pressure,
which may cause acute heart failure
Rheumatic heart disease and congenital
disease cause the majority of chronic
cases
Aortic Regurgitation
In acute disease dyspnea most common presenting symptom
(50% of cases)
many cases have acute pulmonary edema
with pink frothy sputum
fever, chills - if endocarditis cause
Aortic Regurgitation
Dissection of the ascending aorta typically
produces a tearing chest pain - may
radiate between the shoulders
ECG changes w/aortic dissection ischemia or findings of acute inferior MI suggestive of right coronary artery
involvement
Aortic Regurgitation
Chest xray- in acute state demonstrates
acute pulmonary edema with less cardiac
enlargement than expected
Aortic Regurgitation
In chronic disease,
the ventricle progressively dilates to
accommodate the regurgitant blood volume
Marked peripheral vasodilation
Aortic Regurgitation
Chronic regurgitation
1/3 of patients have palpitations associated
with a large stroke volume and/or premature
ventricular contractions
Frequently, these sensations are noticed in
bed
Aortic Regurgitation
Chronic Regurgitation
wide pulse pressure with prominent
ventricular impulse
water hammer pulse may be noted
(peripheral pulse that has a quick rise in
upstroke followed by peripheral collapse)
Aortic Regurgitation
Murmur
high pitched blowing diastolic murmur
immediately after S2
Heart Sounds
S3 may be present; wide pulse pressure
Aortic Regurgitation
An association between the appetite suppressant drugs (fenfluramine and
phentermine or dexfenfluramine) has also
been found for aortic incompetence
Tricuspid Stenosis
Usually rheumatic in origin
should be suspected when right heart
failure appears in course of mitral valve
disease - marked by hepatomegaly,
ascites, and dependent edema
May also occur in carcinoid syndrome
Tricuspid Stenosis
Typical diastolic rumble along lower left
sternal border mimics mitral stenosis
in sinus rhythm, a presystolic liver
pulsation noted
Echocardiography & doppler
Cardiac Cath - diagnositic
Tricuspid Stenosis
Surgical options
valvotomy
prosthetic valve replacement
balloon valvuloplasty (experience limited)
may be initial procedure
Tricuspid Regurgitation
Right ventricle overload - result of left
ventricular failure of any cause
occurs in conjunction with right
ventricular and inferior MI
IV drug users - tricuspid valve
endocarditis and regurgitation common
Tricuspid Regurgitation
Other causes
carcinoid syndrome
lupus erythematosus
myxomatous degeneration of the valve
(associated with MVP)
Ebstein’s anomaly
Tricuspid Regurgitation
Signs/symptoms
identical to those of right ventricular failure
In presence mitral valve disease early onset right heart failure
harsh systolic murmur - lower left sternal border
- (separate from mitral murmur)
Tricuspid Regurgitation
Prominent regurgitant systolic v wave in
right atrium and jugular venous pulse
regurgitant wave, systolic murmur
increased with inspiration
Inspiratory S3 may be present
when secondary to mitral valve disease or
other left sided disease my regress when
underlying disease corrected
Tricuspid Regurgitation
Surgical repair
valve repair or valvuloplasty of tricuspid ring
preferred to valve replacement
Questions ??