STEPTRACKERCARDIOVASCULAR | PATHOLOGY + PHYSIOLOGY | HIGH-YIELD REVIEW

Valvular Disease & Murmurs

Each valve can be too tight or too leaky — the murmur's timing, location and response to maneuvers name the lesion.

FOCUS ON
Know each lesion's cause, murmur and consequence. AS: calcific or bicuspid, ejection murmur to the carotids, syncope/angina/dyspnea. AR: early diastolic, bounding pulses. MS: rheumatic, opening snap + rumble, AF. MR: holosystolic to the axilla. MVP: mid-systolic click. Then learn the maneuvers.
LESION
CAUSES
MURMUR · SIGNS
CONSEQUENCES
Aortic stenosis
Age-related calcification (> 70); bicuspid valve (50s); rheumatic (with MS)
Crescendo-decrescendo SEM at RUSB → carotids; ejection click (bicuspid); soft S2; pulsus parvus et tardus
Exertional syncope, angina, dyspnea · concentric LVH · schistocytes; Heyde syndrome (GI angiodysplasia bleeding)
Aortic regurgitation
Root dilation (Marfan, syphilis, HTN, ankylosing spondylitis), bicuspid valve, endocarditis, rheumatic
Early diastolic decrescendo blowing murmur at left sternal border (sit forward, exhale); wide pulse pressure, bounding pulses, head bobbing
Eccentric LVH → HF; Austin Flint rumble
Mitral stenosis
Almost always rheumatic heart disease
Opening snap after S2, then mid-diastolic rumble at apex (left lateral decubitus)
LA dilation → AF, thrombus, stroke; hoarseness (recurrent laryngeal), dysphagia; pulmonary HTN; worse in pregnancy
Mitral regurgitation
MVP, ischemia (papillary dysfunction/rupture), LV dilation, rheumatic, endocarditis
Holosystolic blowing murmur at apex → axilla; ↑ with handgrip
LA and LV volume overload → HF, AF
Mitral valve prolapse
most common valve lesion
Myxomatous degeneration; Marfan, Ehlers-Danlos, ADPKD
Mid-systolic click + late systolic murmur; click earlier with Valsalva/standing
Usually benign; can cause MR, endocarditis, arrhythmia
Tricuspid regurgitation
RV dilation (pulmonary HTN), IV-drug endocarditis, carcinoid, Ebstein
Holosystolic at LLSB, ↑ with inspiration; prominent v waves, pulsatile liver
Right HF
Pulmonic stenosis
Congenital (Noonan), carcinoid, tetralogy
SEM at LUSB, ↑ with inspiration; ejection click
RVH
Carcinoid heart disease
Serotonin from liver metastases reaches the right heart
Tricuspid regurgitation + pulmonic stenosis (plaques on right-sided valves)
Flushing, diarrhea, wheeze; ↑ urine 5-HIAA

Mechanism — pressure vs volume overload

Stenosis (AS)Pressure load
→
Concentric LVHStiff, diastolic dysfunction
Regurgitation (AR, MR)Volume load
→
Eccentric LVH / dilationSystolic failure
Mitral stenosis
→
LA pressure ↑AF, thrombus
→
Pulmonary congestion→ pulmonary HTN → RV failure

Bedside maneuvers

MANEUVER
LOUDER
SOFTER
Inspiration (↑ venous return to right)
Right-sided murmurs
—
Handgrip (↑ afterload)
MR, AR, VSD
AS, HCM
Valsalva / standing (↓ preload)
HCM; MVP click earlier
Most others, incl. AS
Squatting / leg raise (↑ preload)
AS and most murmurs
HCM; MVP click later

How it's tested

COMMON CONFUSIONAS and HCM both cause systolic ejection murmurs. Valsalva softens AS and makes HCM louder.
THE TRAPOnce a patient with severe AS has symptoms (syncope, angina, dyspnea), survival is short without valve replacement. "Watchful waiting" is wrong.
YOUR APPROACHTiming (systolic/diastolic) → location and radiation → extra sounds (click, snap) → maneuver response → cause.

If you see… think…

80-year-old, exertional syncope, SEM to carotids, slow-rising pulse → calcific aortic stenosis
AS with an ejection click in a 50-year-old → bicuspid aortic valve
Aortic stenosis + GI bleeding from angiodysplasia → Heyde syndrome
Bounding pulses, head bobbing, early diastolic murmur → aortic regurgitation
Opening snap + apical diastolic rumble + AF → rheumatic mitral stenosis
Mitral stenosis with hoarseness → enlarged LA compressing the recurrent laryngeal nerve
Holosystolic apical murmur radiating to the axilla → mitral regurgitation
Young woman, palpitations, mid-systolic click → mitral valve prolapse
IV drug user, holosystolic LLSB murmur louder on inspiration → tricuspid regurgitation
Flushing, diarrhea and right-sided valve disease → carcinoid heart disease