Mitral regurgitation MR occurs when there is backflow regurgitation of blood from the left ventricle into the left atria through the mitral valve during ventricular systole. Mitral regurgitation is associated with a pansystolic murmur heart loudest over the mitral area and radiating to the axilla.
Aortic regurgitation AR occurs when there is backflow of blood from the aorta into the left ventricle during ventricular diastole. Aortic regurgitation is associated with an early diastolic murmur heard loudest at the left sternal edge. Aortic regurgitation can be either acute or chronic. Chronic AR is often asymptomatic. AR can occur due to a disease process affecting the valve itself, or due to dilatation of the aortic root.
There are many eponymous clinical signs associated with aortic regurgitation. These include:. Mitral stenosis MS is narrowing of the mitral valve, which results in decreased filling of the left ventricle during systole and increased left atrial pressure due to incomplete left atrial emptying. Mitral stenosis is associated with a low-pitched, rumbling, mid-diastolic murmur heard loudest over the apex.
A mitral valve prolapse occurs when the mitral valve leaflets prolapse into the left atrium during systole. Mitral valve prolapse is associated with a combination of a mid-systolic click and mid to late-systolic murmur. The exact underlying cause of mitral valve prolapse is unknown. Primary mitral valve prolapse is caused by myxomatous degeneration of the mitral valve and is associated with connective tisuse diseases.
Tricuspid regurgitation occurs when there is backflow of blood from the right ventricle into the right atrium during ventricular systole. This causes an increase in right atrial pressure and elevated venous pressures. Tricuspid regurgitation is associated with a pansystolic murmur heard loudest over the tricuspid region. The Ebstein anomaly i. Pulmonary stenosis PS refers to narrowing of the pulmonary valve.
It is commonly associated with other congenital heart defects. Pulmonary regurgitation PR occurs when there is backflow of blood from the pulmonary artery into the right ventricle during ventricular diastole.
Pulmonary regurgitation is rare. Tricuspid stenosis is associated with a soft diastolic murmur loudest at 3rd — 4th intercostal space at the left sternal edge. Table 2. A table summarising the key differences between different heart murmurs. Clinical Examination. An Introduction to the Arclight. Eye Drops Overview. Statin Counselling. Prescribing in Renal Impairment. Interpreting Hepatitis B Serology. Medicine Flashcard Collection. A collection of surgery revision notes covering key surgical topics.
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Activate Account. Create a New Account. Forgot Username or Password? Types of murmurs include: Systolic murmur - occurs during a heart muscle contraction. Systolic murmurs are divided into ejection murmurs due to blood flow through a narrowed vessel or irregular valve and regurgitant murmurs. Diastolic murmur - occurs during heart muscle relaxation between beats. Diastolic murmurs are due to a narrowing stenosis of the mitral or tricuspid valves, or regurgitation of the aortic or pulmonary valves.
Continuous murmur - occurs throughout the cardiac cycle. Occasionally, mitral stenosis is congenital or occurs after radiation therapy. If the valve cannot close completely, mitral regurgitation Mitral Regurgitation Mitral regurgitation MR is incompetency of the mitral valve causing flow from the left ventricle LV into the left atrium during ventricular systole. MR can be primary common causes are Patients with mitral stenosis due to rheumatic fever may also have lesions of the aortic or tricuspid valve or both.
Left atrial LA size and pressure increase progressively to compensate for mitral stenosis; pulmonary venous and capillary pressures also increase and may cause secondary pulmonary hypertension Symptoms and Signs Pulmonary hypertension is increased pressure in the pulmonary circulation.
It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels become constricted Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid The most common cause is dilation of the The most common cause is Rate of progression varies. LA enlargement predisposes to atrial fibrillation Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm.
Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form The faster heart rate and loss of atrial contraction with onset of AF often lead to sudden worsening of symptoms. Symptoms of mitral stenosis correlate poorly with disease severity because the disease often progresses slowly, and patients unconsciously reduce their activity. Many patients are asymptomatic until they become pregnant or AF develops.
Initial symptoms are usually those of heart failure eg, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue. Symptoms typically do not appear until 15 to 40 years after an episode of rheumatic fever. In medically underserved countries, young children may become symptomatic because streptococcal infections may not be treated with antibiotics and recurrent infections are common. Paroxysmal or chronic atrial fibrillation further reduces blood flow into the left ventricle LV , precipitating pulmonary edema Pulmonary Edema Pulmonary edema is acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding.
Findings are severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged AF may also cause palpitations. Less common symptoms include hemoptysis due to rupture of small pulmonary vessels and pulmonary edema, particularly during pregnancy when blood volume increases.
Hoarseness due to compression of the left recurrent laryngeal nerve by a dilated LA or pulmonary artery Ortner syndrome and symptoms of pulmonary hypertension Symptoms and Signs Pulmonary hypertension is increased pressure in the pulmonary circulation.
Mitral stenosis may cause signs of cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular enlargement secondary to a lung disorder that causes pulmonary artery hypertension. Right ventricular failure follows. Findings include peripheral edema, neck The classic facial appearance in mitral stenosis, a plum-colored malar flush, occurs only when cardiac output is low and pulmonary hypertension is severe; cause is cutaneous vasodilation and chronic hypoxemia. Occasionally, the initial symptoms and signs of mitral stenosis are those of an embolic event such as stroke.
Endocarditis is rare in mitral stenosis unless mitral regurgitation is also present. Palpation may detect palpable 1st and 2nd heart sounds S1 and S2. S1 is best palpated at the apex, and S2 at the upper left sternal border. The pulmonic component of S2 P2 is responsible for the impulse and results from pulmonary hypertension. An RV impulse heave palpable at the left sternal border may accompany jugular venous distention when pulmonary hypertension is present and RV diastolic dysfunction develops.
Auscultatory findings in mitral stenosis include a loud S1 caused by the leaflets of a stenotic mitral valve closing abruptly M1 ; it is heard best at the apex. S1 may be absent when the valve is heavily calcified and immobile. A normally split S2 with an exaggerated P2 due to pulmonary hypertension is also heard see table Distinguishing the Murmurs of Tricuspid Stenosis and Mitral Stenosis Distinguishing the Murmurs of Tricuspid Stenosis and Mitral Stenosis Mitral stenosis is narrowing of the mitral orifice that impedes blood flow from the left atrium to the left ventricle.
Common complications Most prominent is an early diastolic opening snap as the leaflets billow into the LV, which is loudest close to left lower sternal border; it is followed by a low-pitched decrescendo-crescendo rumbling diastolic murmur, heard best with the bell of the stethoscope at the apex or over the palpable apex beat at end-expiration when the patient is in the left lateral decubitus position.
The opening snap may be soft or absent if the mitral valve is calcified; the snap moves closer to S2 increasing duration of the murmur as mitral stenosis becomes more severe and LA pressure increases.
The diastolic murmur increases after a Valsalva maneuver when blood pours into the LA , after exercise, and in response to maneuvers that increase afterload eg, squatting, isometric handgrip.
The murmur may be softer or absent when an enlarged RV displaces the LV posteriorly and when other disorders pulmonary hypertension, right-sided valve abnormalities, AF with fast ventricular rate decrease blood flow across the mitral valve.
The presystolic crescendo is caused by increased flow with atrial contraction. However, the closing mitral valve leaflets during LV contraction may also contribute to this finding but only at the end of short diastoles when LA pressure is still high. Early diastolic murmur of coexisting aortic regurgitation Aortic Regurgitation Aortic regurgitation AR is incompetency of the aortic valve causing backflow from the aorta into the left ventricle during diastole.
Causes include valvular degeneration and aortic root dilation Graham Steell murmur a soft decrescendo diastolic murmur heard best along the left sternal border and caused by pulmonic regurgitation Pulmonic Regurgitation Pulmonic pulmonary regurgitation PR is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole.
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