Dynamic Auscultation of Heart Sounds and...

Dynamic Auscultation ofHeart Sounds and Murmurs

W. Lane Edwards, Jr., MSN, ARNP, ANPHospitalist Group of Southwest Florida

Affiliate Professor of Nursing, University of Alaska at Anchorage

AcknowledgementThe sounds you hear today are

complements of “Listening to the Heart” by Daniel Mason, MD., Professor of Medicine, Drexel University College of MedicineUniversity College of Medicine, Hahnemann University Hospital, Philadelphia, Pa.

Copyright release 10-9-08 to Partners in Healthcare Education, LLC for 10-18-08 Presentation to Take Care Health System for internal use only.

DisclosuresReal or Potential Conflicts of Interest

W. Lane Edwards, Jr., MSN, ARNP,ANPRecipient of Grant/Research Support

Roche, GSK, Merck, AZ, Novartis, Proctor and Gamble, Pfizer

Speakers BureauMerck, Takeda, AstraZeneca, Novartis, Roche, Novartis, Pfizer

Major Stock/ShareholderNone

3

Where are we?

Differentiate Mitral Regurgitation from Aortic Stenosis?Differentiate Systolic from Diastolic

©Edwards 2008

Differentiate Systolic from Diastolic Murmurs?Differentiate S3 from S4?Recognize a stethoscope 4 out of 5 trys?

Physiologic ApproachKey to Understanding the creation of “noise” within the cardiovascular system is based on

©Edwards 2008

is based on What causes that noise

S4 – atrial contractionSignificant aid in retention of sounds.

I repeat myself………Some say it is a sign of aging.Some say that I just ramble.Some attribute it to SDAT in my f lfamily

My excuse is a learning theory that says repetition strengthens learning, that’s my story, and I am sticking with it.

Heart Sounds and MurmursObjectives

Describe a murmur by timing, radiation, characteristics, and point of intensityGrade a murmur by its auscultatory

©Edwards 2008

Grade a murmur by its auscultatory characteristicsDifferentiate systolic from diastolic murmurs by clinical presentation

Objectives …..Distinguish split heart sounds from S3 & S4 by characteristics and timingDifferentiate first and second heart

©Edwards 2008

Differentiate first and second heart sounds by characteristics and location of soundsProvide the physiologic rationale for creation of the 3rd & 4th heart sounds.

Objectives…...Identify the clinical presentation of selected lesions of the aortic and mitral valves

©Edwards 2008

valvesDiscuss the medical and surgical treatment for each valve lesion.

Today’s AgendaAnatomyCirculationCreation of Heart

First Heart SoundSecond Heart Sound

-Split Sounds

©Edwards 2008

Creation of Heart SoundsThe Cardiac CycleAnticipation !Ascultatory Positions

Third Heart SoundFourth Heart SoundSummation Gallop

Part II - The MurmursDescription of MurmursCharacteristics

Aortic StenosisAortic InsufficiencyMitral Insufficiency

©Edwards 2008

HolosystolicDecrescendoCrescendo

Grading of Murmurs

Mitral InsufficiencyMitral StenosisProsthetic Valves

Circulation Review

©Edwards 2008

Types of ValvesPressure

Aortic & PulmonicDependent onDependent on pressure gradients

Structural Support Mechanisms

Mitral & TricuspidCordae and papillary muscles

Right Atrium and Tricuspid Valve

Unidirectional blood flow from RA to RVRt. Atria ExpansionRt. Atrial Mixing

different O2 satsTricuspid Valve

low pressuresmall supportstructures

Low pressure gradient

Tricuspid Valve

Pulmonic Valve•Unidirectional blood

flow from RV to PulmonaryPulmonary circuit

•Pressure valve•No structural support•Moderate pressure gradient

Pulmonic Valve

Left Atrium and Mitral Valve

Lt Atria Fixed SizeMitral Valve

more cordaemore cordaestronger papillary

musclespart of inferior wallInferior MI issuesPressure issuesNo Valves to Lungs

Mitral Valve

Mitral Valve Open and Closed

Aortic Valve

Normal vs Bicuspid Aortic Valve

Aortic Cusps

Systolic - Diastolic

The Cardiac

©Edwards 2008

The CardiacCycle

©Edwards 2008

Rapid LV FillingMitral Valve OpensBlood stored in prior cycle rushes into left ventricle.If Preload high

S3

DiastosisAs the Mitral Valve is open, blood continues to fill from h hthe LA to the LV

increasing pressure and wall tension

Atrial ContractionFollowing the P wave of the EKG, the atria contract augmenting anotheraugmenting another 20-30% volume increase in LVIf large preload

S4

Both Doors Closed ….When pressure in Lt Ventricle exceeds that of the LA, the

l l lmitral valve closesAortic Valve is closedRoom get smaller!Pressure goes up

Aortic EjectionWith the Mitral valve prevented from opening by chordae

d lland papillary musclesAortic valve set by pressure above the valvePressure in LV increases

Aortic Valve OpensWith pressure below the valve higher than above the

l hvalve, the aortic valve opensWhen ventricle empties and the pressure is less in LV, aortic valve cusps fill with blood and close

What if….Mitral valve can’t open adequatelyMitral Valve can’t close during systoleAortic valve can’t open wellAortic valve can’t close well

Anticipation of Abnormals

Rhythm Disturbances - Conduction Abnormalities

Atrial Fibrillation - Atrial Flutter

©Edwards 2008

Atrial Fibrillation Atrial FlutterAtrio-ventricular ids-associationPacemaker rhythmsBundle Branch Blocks

Intraventricular Conduction Delays


History of Hypertension

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Mitral RegurgitationS3S4


Congestive Heart Failure

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Mitral RegurgitationS3S4


Volume / Pressure Overloads

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Splitting of Heart SoundsS3S4


Valvular Abnormalities

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Ejection Sounds, ClicksOpening SnapsKnocks, plopps

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The tool…

Listening to The Heart. Daniel Mason, MD. Second Edition. FA Davis. 2000

Apical

Left Lower

Aortic

Pulmonic

Anatomical Auscultation Points

Left Lateral Sternal BorderRt. Heart and triscuspid valve4th ICS, Left Sternal Border

©Edwards 2008

4th ICS, Left Sternal BorderApex

Lt. Heart or Mitral area5th intercostal space, mid clavicular line

Anatomical Auscultation Points

Base LeftPulmonic Area2nd ICS, Left of Sternum

©Edwards 2008

2nd ICS, Left of SternumMitral & Aortic Sounds also heard

Base RightAortic Area2nd ICS, Right of Sternum

Normal First Heart Sound

Closure Mitral -Tricuspid ValvesOccurs with onset of

©Edwards 2008

Occurs with onset of the apical pulse and carotid pulsationHeard loudest at the apex and LLSB with diaphram (high)

Normal S2Closure of Aortic & Pulmonic ValvesS1 longer & lower

©Edwards 2008

gS2 is shorter & sharperAortic 1st; A2P2Base Of Heart with diaphram (high)

Listen

Splitting of S2p gNormal Split

Physiological SplitParadoxical Split

Closing OrderLeft Ventricle

Normal (physiological)Aortic –Pulmonic A2-P2

Abnormal (paradoxical)Pulmonic Aortic P2 A2

Normal Split S 2Splitting during inspiration is normalExpiration the

©Edwards 2008

splitting will do awayIncreased blood intake into Rt. Heart during inspiration

Listen

Paradoxical Split S 2Abnormally Wide Split S 2

Heard split in inspiration and expiration

©Edwards 2008

Best heard base Lt. with diaphramRBBB, LBBBPulmonary Stenosis

Paradoxical

Fixed

Listen

S 3Opening of Mitral Valve - rush inVentricular Overload

Myocarditis

©Edwards 2008

MyocarditisCHF, Tachy’s

Bell over Apex - Lt. Lateral RecumbentPhysiologic in young <30 (!)

S 3

S 3

Listen

Fourth Heart Sound S4

Caused by Atrial ContractionIncreased LV Stiff

©Edwards 2008

Primary Myo DzHtnCADAortic PulmonaryStenosis

Bell at Apex

S4

Listen

Listen

Normal vs Bicuspid Aortic Valve

Listen

©Edwards 2008

Describing a MurmurTiming - Systolic Vs DiastolicIdentify area heard loudestIdentify radiation of sound

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Identify radiation of soundIdentify Duration and Characteristics

Grading of MurmursGrade I

very faint - takes several cycles to hear

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hear

Grade IIquiet, but heard immediately, firstcycle

Grading of MurmursGrade III

Moderately loud, but without thrill

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Grade IVloud, may be associated with a thrill

Grading of MurmursGrade V

very loud,may be heard with a stethoscope partly off the chest,

©Edwards 2008

stethoscope partly off the chest, usually associated with a thrill

Grade VIHeard with stethoscope off the chesthas a thrill

Listen

Systolic

Diastolic

The Misconception

©Edwards 2008

Mitral Regurgitation

l S

Electrocardiogram

Mitral Stenosis

Aortic Stenosis

Aortic Insufficiency

When Do I get an echo?New discovery of murmurChange in clinical presentationAnnually for grade 3 or above murmursAnnually for grade 3 or above murmursChange in LV function

Listening for Aortic Stenosis

Aortic Stenosis

Aortic Valve Vegetations

Aortic Stenosis

Pathophysiology AS

Clinical – low output state

Aortic Stenosis

Aortic StenosisLow forward flow

Dizzinessfatiguefatigue

LV geometry changesFibrillation possible

LA pressure upPulmonary back pressure

Listen

Afterload reductionPreload reductionPVR

Treatment of AS

PVRIncreased Intravascular VolumeAnti platelet

AorticAorticInsufficiency

AorticffInsufficiency

Aortic Insufficiency Compromised diastolic filling of coronary arteriescoronary arteriesIABPcontraindicatedEnhanced preload – LVLVH as compensation



Listen


Treatment of AI


MitralMitral Insufficiency

Listening

Mitral Insufficiency

Acute

Cordal Rupture

Chronic

Increasing LV


Cordal RuptureInferior wall MIPapillary Muscle RuptureVegetations on leaflet

Increasing LV geometry changesIncreasing MR

Large LAHigh Pulmonary PressureReflection to Lungs


Reflection to LungsLVHRt. Heart Failure

Primary clinical –Respiratory complaints


Listen


Treatment of MI


Listening to MS

Normal Mitral Valves

Mitral Stenosis

Mitral Stenosis

Thrombus Left Atria


Mitral StenosisHuge Left AtriaMural ThrombusArrhythmia controlLow forward flow

Right heart failureMinimal LV geometry changesMostly Pulmonary with some decreased flow

Listen


Treatment of MS


Left Atrial Mixoma

Listen

Prosthetic ValvesProsthetic Valves

Dynamic Auscultation of Heart Sounds and...

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