Cardiac defects

- Aortic stenosis
- Aortic regurgitation
- Mitral stenosis
- Mitral regurgitation
- Tricuspid stenosis
- Tricuspid regurgitation
- Pulmonary stenosis
- Pulmonary regurgitation
- Valvular prostheses
Congenital defects
- Atrioseptal defect
- Ventriculoseptal defect
- Open arterial duct
- Coarctation of the aorta
- Fallot´s tetralogy
- Ebstein´s anomaly

Aortic stenosis
Is mostly congenital or it develops as a result of on degenerative changes (often in the congenital bicuspid valve) or following an episode of rheumatoid endocarditis.
   Congenital 60%,
   Degenerative 30%
   Rheumatoid (as a part of combined aortic mitral defect) 10%
Stenoses can be classified into 2 types:
   Subvalvular (hypertrophic obstructive cardiomyopathy)
   Rising apex beat (left ventricle hypertrophy), palpable whirl over the aortic opening.
   Blunt 1st sound.
   Early systolic click (providing the valve is not yet calcified).
   Ejection systolic murmur over the aorta, of crescendo-decrescendo character, with propagation to the carotid.
   Pulse: pulsus parvus et tardus /small and slow/ - small systolic range of blood pressure.
Clinical triad:
   1) stenocardia
   2) exertional dyspnoea
   3) syncope (in exertion a critical reduction of the minute cardiac output or due to obstruction of the discharge part of the left ventricle - temporary cerebral hypoxia; arrhythmia.

Character and
propagation of
murmur in
aortic stenosis

Aortic regurgitation
   Dilation of the root of the aorta (e.g. Marfan´s syndrome)
   Dissection of the ascending aorta
   Infectious endocarditis
   Congenital bicuspid valve
   Blowing diastolic murmur over the aortic orifice, of decrescendo character, with a maximum at Erb´s point (3rd intercostal space on the left near the sternum), i.e. along the left margin of the sternum, stronger in the sitting position, propagation towards the heart apex.
   SometimesAustin Flint's murmur is heard at the apex - diastolic mitral murmur resembling mitral stenosis. It is caused by the premature closure of the front mitral valve cusp with the stream of regurgitating aortic blood, thus the front mitral cusp produces relative stenosis of the mitral orifice.
   Great systolic-diastolic range of blood pressure, diastolic BP (blood pressure) sometimes cannot be measured ("infinite tone" phenomenon).
   Jerky Corrigan's pulse (magnus, celer et altus = great, fast and high).
   Quincke's sign (pressure on the end of the nail results in pulsation of the lunula margin).
   Musset's sign (rhythmical jerking movement of the head with pulsation).
   X-ray photography of the heart and lungs – the aortic shape of the heart accentuation of the small arch of the left ventricle and the aorta and the incisure between them - always a result of an episode of endocarditis.
   ECG: left ventricular hypertrophy.
Clinical symptoms:
   Long-term asymptomatic (long-term tolerated output load of the left ventricle).
   Exertional dyspnoea.


Character and
propagation of
murmur in aortic

Mitral stenosis
Aetiology is always postrheumatic.
Auscultation triad
   Modified 1st sound, accentuated, intensified, corresponds with the closure of the mitral valve under great tension.
   2nd sound - followed by the mitral opening sound in early diastole ("opening snap"), when the balloon-like bulging stenotic valve cannot open more during diastole and starts to vibrate.
   The mitral opening sound is followed with mesodiastolic-presystolic rumbling murmur at the apex (in atrial fibrillation the presystolic component of murmur is absent).
Auscultation is performed with the bell-shaped stethoscope,the sound can be increased by an exercise, the patient is lying on the left side (which intensifies the sound). The sound resembles the calling of a quail (quac-ke-le).
Examples of analysis of auscultation findings:
Mitral stenosis
Accentuation - 1st sound
Mitral opening sound
Short diastolic murmur
Presystolic murmur
Tricuspididation (i.e. hypertrophy and dilation of the right ventricle) produces:
   Relative pulmonary regurgitation - diastolic Graham's and Steell´s murmur.
   Relative tricuspid regurgitation - systolic murmur.
These murmurs from the right heart are accentuated in inspiration (i.e. the increased negative intrathoracic pressure, increased return of venous blood to the right atrium) - Rivero-Carvallo's sign.
It is necessary, by means of differential diagnostics, to differentiate the diastolic Austin Flint's murmur in aortic regurgitation, when the stream of regurgitating blood from the aorta results in premature closure and relative stenosisof the mitral valve - it obstructs the way with mitral valve front cusp in this phase of left ventricle diastolic filling. The opening mitral sound is absent.
X-ray picture of the heart + lungs - mitral shape of the heart
ECG: mitral P vawe, or atrial fibrillation; right ventricle hypertrophy, or right Tawara's node  block.
Clinical symptoms:
   The first symptom is fatigue, later progressive exertional dyspnoea.
   Dilatation of the left atrium occurs; danger of the development of atrial fibrillation and atrial thrombi - danger of a systemic embolisation (into the CNS, extremities.)
   Facies mitralis (mitral face), i.e. the appearance of the patient's face marked by rose, flushed cheeks, and dilated capillaries.
   Pulmonary oedema (due to postcapillary pulmonary hypertension), later "tricuspidation of the defect" (due to the fixed precapillary pulmonary hypertension and secondary due to right heart insufficiency) - i.e. the triad of the right heart failure.


Character and
propagation of
murmur in
mitral stenosis

Mitral regurgitation
   Mitral valve prolapse of the mitral valve.
   Ischaemic heart disease (IHD - acute myocardial infarction leading to dysfunction of the papillary muscle or rupture of the supporting apparatus of the mitral valve, secondary due to left ventricle dilatation).
   Postrheumatic (combined mitral defect).
   Infectious endocarditis.
   Congenital (e.g. congenital cleft of the front cusp of the mitral valve)
Auscultatory reduction or even disappearance of the 1th sound, a holosystolic murmur at the apex with propagation to the axilla.
Mitral regurgitation
Systolic murmur a)
Systolic murmur b)
Systolic murmur c) crescendo type
Late systolic murmur of crescendo type
Systolic murmur d) holosystolic
Clinical symptoms:
   Long-term asymptomatic
Resulting in hypertrophy and dilatation of the left atrium and left ventricle.
   Combined mitral defect (mitral regurgitation + stenosis)
Tricuspid stenosis (very rare)
Aetiology is post-rheumatic, obstructed blood inflow to the right ventricle, leads to congestion and dilatation of the right atrium.
Auscultation finding: diastolic murmur above the lower sternum (intensified in inspiration)


Character and
propagation of
murmur in mitral

Tricuspid regurgitation
   Infectious endocarditis (mainly in intravenous drug addicts).
   Secondary due to dilatation of the right ventricle.
These lead to a volume overload of the right ventricle with consequent right heart insufficiency.
Auscultation finding: holosystolic regurgitation murmur over the lower sternum (intensified in inspiration).
Pulmonary stenosis
Aetiology: mostly occurs as a part of congenital cardiac defects - e.g. Fallot´s tetralogy.
Auscultation finding: ejection systolic murmur over the pulmonary artery.
It leads to right ventricle hypertrophy with subsequent dilatation and secondary to development of tricuspid regurgitation and right heart insufficiency.
Pulmonary regurgitation
Aetiology: develops secondarily due to pulmonary hypertension (conditions eliciting pulmonary hypertension - e.g. cor pulmonale, tricuspidated mitral stenosis etc.)
Auscultation finding: diastolic murmur over the pulmonary artery - Graham´s and Steell´s murmur
Mechanical valvular prostheses
Auscultation finding click and murmur from the valvular flow. Their differentiation is as follows:
   In the mitral position - accentuated 1st sound.
   In the aortic position - accentuated 2nd sound, murmurs in the systolic phase.
The most frequent congenital cardiac defects (CCD)


1. Atrioseptal defect
The blood flows from left to right - L-R shunt, which leads to volume overload of the right heart, and right ventricle dilatation; when a secondary pulmonary disease and hypertension in the pulmonary bed develops, the shunt changes to R-L (i.e. from right to left) - so called Eisenmenger´s complex.
Auscultation finding: systolic murmur over the pulmonary artery + fixed segregation of the 2nd sound (2nd sound in diastole - i.e. under normal conditions, the aortic valve closes first followed by the pulmonary valve; here, it closes much later after the aortic valve, due to right ventricle dilatation and overload, therefore it is fixed, physiological segregation of the 2nd sound).
2. Ventricular septal defect
Membranous type or muscular type, gradual development of the volume overload of the left ventricle, L-R as well as R-L shunts.
Auscultation finding: pansystolic murmur in the 3rd to 4th intercostal space in the left parasternal region with propagation to the right.
3. Patent ductus arteriosus (Botallo´s duct)
Foetal duct from the pulmonary artery to the aorta fails to close; therefore the normal foetal circulation is maintained, blood flows from the aorta to the pulmonary artery (L-R shunt), later, the development of pulmonary hypertension leads to reverse of the shunt to R-L (Eisenmenger´s complex) and development of cyanosis.
Auscultation: continuous systolic-diastolic machinery murmur below the left clavicle, the maximum being during the 2nd sound.
4. Coarctation of the aorta
The occurrence of supra-valvular aortal stenosis in the site of the isthmus, leading to hypertension in upper extremities and hypotension in lower extremities.
Auscultation findings: systolic murmurs in the precordium with propagation to the back between the shoulder blades. The blood pressure is increased in upper extremities, low in the lower extremities (the difference upper extremity/lower extremity is equal or higher than 20 mm Hg).
5. Fallot´s tetralogy
It is a congenital, cyanotic defect, comprising of 4 anomalies:
   Pulmonary artery stenosis
   Right ventricle hypertrophy
   Defect of the ventricular septum
   The overriding aorta
Clinical symptoms: leads to cyanosis, which is present from the birth, dyspnoea, erythrocythaemia, and digital clubbing. Auscultatory finding corresponds with single anomalies, which can be of variable significance.
6. Ebstein´s anomaly
Septal cusp of the tricuspid valve is attached closer to heart apex, which leads to extension of the right atrium and reduction of the right ventricle and development of tricuspid regurgitation. This results in pulmonary hypertension.
Auscultation finding: systolic regurgitation murmur over the lower sternum due to tricuspid regurgitation.


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