Differential diagnosis of valvular heart disease

Mitral Stenosis Mitral

Regurgitation
Aortic Stenosis Aortic Regurgitation Tricuspid
Stenosis
Tricuspid
Regurgitation
Inspection Malar flush,
precordial bulge,
and diffuse
pulsation in
young patients.
Usually prominent
and hyperdynamic
apical impulse to left
of MCL.
Sustained PMI,
prominent atrial
filling wave.
Hyperdynamic PMI to
left of MCL and
downward. Visible
carotid pulsations.
Pulsating nailbeds
(Quincke), head bob
(deMusset).
Giant a wave in
jugular pulse with
sinus rhythm.
Peripheral edema
or ascites, or
both.
Large v wave in
jugular pulse;
time with carotid
pulsation.
Peripheral edema
or ascites, or
both.
Palpation "Tapping"
sensation over
area of expected
PMI. Right
ventricular
pulsation left
third to fifth ICS
parasternally
Forceful, brisk PMI;
systolic thrill over
PMI. Pulse normal,
small, or slightly
collapsing.
Powerful,
heaving PMI to
left and slightly
below MCL.
Systolic thrill
over aortic area,
sternal notch, or
carotid arteries
Apical impulse
forceful and displaced
significantly to left
and downward.
Prominent carotid
pulses. Rapidly rising
and collapsing pulses
(Corrigan pulse).
Pulsating,
enlarged liver in
ventricular
systole.
Right ventricular
pulsation.
Systolic
pulsation of
liver.
when pulmonary
hypertension is
present. P
2
may
be palpable.

in severe
disease. Small
and slowly
rising carotid
pulse. If
bicuspid AS
check for delay
at femoral
artery to
exclude
coarctation.
Heart sounds,
rhythm, and blood
pressure
S
1
loud if valve
mobile. Opening
snap following
S
2
. The worse
the disease, the
closer the S
2
-
opening snap
interval.

S
1
normal or buried
in early part of
murmur (exception is
mitral prolapse where
murmur may be late).
Prominent third heart
sound when severe
MR. Atrial
fibrillation common.
A
2
normal, soft,
or absent.
Prominent S
4
.
Blood pressure
normal, or
systolic
pressure normal
with high
diastolic
S
1
normal or reduced,
A
2
loud. Wide pulse
pressure with diastolic
pressure < 60 mm Hg.
When severe, gentle
compression of
femoral artery with
diaphragm of
stethoscope may
S
1
often loud.

Atrial fibrillation
may be present.
Blood pressure
normal. Midsystolic
clicks may be present
and may be multiple.

pressure.

reveal diastolic flow
(Duroziez) and
pressure in leg on
palpation > 40 mm
Hg than arm (Hill).
Murmurs
Location and
transmission
Localized at or
near apex.
Diastolic rumble
best heard in left
lateral position;
may be
accentuated by
having patient
do sit-ups.
Rarely, short
diastolic
murmur along
lower left sternal
Loudest over PMI;
posteriorly directed
jets (ie, anterior
mitral prolapse)
transmitted to left
axilla, left
infrascapular area;
anteriorly directed
jets (ie, posterior
mitral prolapse) heard
over anterior
precordium. Murmur
unchanged after
Right second
ICS
parasternally or
at apex, heard in
carotid arteries
and
occasionally in
upper
interscapular
area. May
sound like MR
at apex
(Gallaverdin
Diastolic: louder
along left sternal
border in third to
fourth interspace.
Heard over aortic area
and apex. May be
associated with low-
pitched middiastolic
murmur at apex
(Austin Flint) due to
functional mitral
stenosis. If due to an
enlarged aorta,
Third to fifth ICS
along left sternal
border out to
apex.Murmur
increases with
inspiration.
Third to fifth
ICS along left
sternal border.
Murmur hard to
hear but
increases with
inspiration. Sit-
ups can increase
cardiac output
and accentuate.
border (Graham
Steell) in severe
pulmonary
hypertension.
premature beat. phenomenon),
but murmur
occurs after
S
1
and stops
before S
2
. The
later the peak in
the murmur, the
more severe the
AS.

murmur may radiate
to right sternal border.
Timing Relation of
opening snap to
A
2
important.
The higher the
LA pressure the
earlier the
opening snap.
Presystolic
accentuation
before S
1
if in
Pansystolic: begins
with S
1
and ends at or
after A
2
. May be late
systolic in mitral
valve prolapse.

Begins after S
1
,
ends before A
2
.
The more
severe the
stenosis, the
later the
murmur peaks.

Begins immediately
after aortic second
sound and ends before
first sound (blurring
both); helps
distinguish from MR.
Rumble often
follows audible
opening snap.
At times, hard to
hear. Begins
with S
1
and fills
systole.Increases
with inspiration.

sinus rhythm.
Graham Steell
begins with
P
2
(early
diastole) if
associated
pulmonary
hypertension.

Character Low-pitched,
rumbling;
presystolic
murmur merges
with loud S
1
.

Blowing, high-
pitched; occasionally
harsh or musical.
Harsh, rough. Blowing, often faint. As for mitral
stenosis.
Blowing, coarse,
or musical.
Optimum
auscultatory
conditions
After exercise,
left lateral
recumbency.
Bell chest piece
After exercise; use
diaphragm chest
piece. In prolapse,
findings may be more
Use stethoscope
diaphragm.
Patient resting,
leaning
Use stethoscope
diaphragm. Patient
leaning forward,
breath held in
Use stethoscope
bell. Murmur
usually louder and
at peak during
Use stethoscope
diaphragm.
Murmur usually
becomes louder
lightly applied. evident while
standing.
forward, breath
held in full
expiration.
expiration. inspiration.Patient
recumbent.
during
inspiration.
Radiography Straight left
heart border
from enlarged
LA appendage.
Elevation of left
mainstem
bronchus. Large
right ventricle
and pulmonary
artery if
pulmonary
hypertension is
present.
Calcification in
mitral valve in
rheumatic mitral
stenosis or in
Enlarged left
ventricle and LA.
Concentric left
ventricular
hypertrophy.
Prominent
ascending
aorta. Calcified
aortic valve
common.
Moderate to severe
left ventricular
enlargement.Aortic
root often dilated.
Enlarged right
atrium with
prominent SVC
and azygous
shadow.
Enlarged right
atrium and right
ventricle.
annulus in
calcific mitral
stenosis.
ECG Broad P waves
in standard
leads; broad
negative phase
of diphasic P in
V
1
. If
pulmonary
hypertension is
present, tall
peaked P waves,
right axis
deviation, or
right ventricular
hypertrophy
appears.

Left axis deviation or
frank left ventricular
hypertrophy. P waves
broad, tall, or notched
in standard
leads.Broad negative
phase of diphasic P in
V
1
.

Left ventricular
hypertrophy.
Left ventricular
hypertrophy.
Tall, peaked P
waves. Possible
right ventricular
hypertrophy.
Right axis usual.
Echocardiography
Two-dimensional
echocardiography
Thickened,
immobile mitral
valve with
anterior and
posterior leaflets
moving
together.
"Hockey stick"
shape to opened
anterior leaflet
in rheumatic
mitral stenosis.
Annular calcium
with thin leaflets
in calcific mitral
stenosis. LA
enlargement,
normal to small
left ventricle.
Thickened mitral
valve in rheumatic
disease; mitral valve
prolapse; flail leaflet
or vegetations may be
seen. Dilated left
ventricle in volume
overload. Operate for
left ventricular end-
systolic dimension >
4.5 cm.
Dense persistent
echoes from the
aortic valve
with poor
leaflet
excursion. Left
ventricular
hypertrophy late
in the disease.
Bicuspid valve
in younger
patients.
Abnormal aortic valve
or dilated aortic root.
Diastolic vibrations of
the anterior leaflet of
the mitral valve and
septum. In acute
aortic insufficiency,
premature closure of
the mitral valve
before the QRS.
When severe, dilated
left ventricle with
normal or decreased
contractility. Operate
when left ventricular
end-systolic
dimension > 5.0 cm.
In rheumatic
disease, tricuspid
valve thickening,
decreased early
diastolic filling
slope of the
tricuspid valve. In
carcinoid, leaflets
fixed, but no
significant
thickening.
Enlarged right
ventricle with
paradoxical
septal motion.
Tricuspid valve
often pulled
open by
displaced
chordae.
Orifice can be
traced to
approximate
mitral valve
orifice area.
Continuous and
color flow Doppler
and TEE
Prolonged
pressure half-
time across
mitral valve
allows
estimation of
gradient. MVA
estimated from
pressure half-
time. Indirect
evidence of
pulmonary
hypertension by
noting elevated
right ventricular
Regurgitant flow
mapped into LA. Use
of PISA helps assess
MR severity. TEE
important in
prosthetic mitral
valve regurgitation.
Increased
transvalvular
flow velocity;
severe AS when
peak jet > 4
m/sec (64 mm
Hg). Valve area
estimate using
continuity
equation is
poorly
reproducible.
Demonstrates
regurgitation and
qualitatively estimates
severity based on
percentage of left
ventricular outflow
filled with jet and
distance jet penetrates
into left ventricle.
TEE important in
aortic valve
endocarditis to
exclude abscess.
Mitral inflow pattern
describes diastolic
Prolonged
pressure half-time
across tricuspid
valve can be used
to estimate mean
gradient.Severe
tricuspid stenosis
present when
mean gradient > 5
mm Hg.
Regurgitant flow
mapped into
right atrium and
venae cavae.
Right ventricular
systolic pressure
estimated by
tricuspid
regurgitation jet
velocity.
systolic pressure
measured from
the tricuspid
regurgitation jet.
dysfunction.


A2, aortic second sound; AS, aortic stenosis; ICS, intercostal space; LA, left atrial; MCL, midclavicular line; MR, mitral
regurgitation; MVA, measured valve area; P2, pulmonary second sound; PISA, proximal isovelocity surface area; PMI, point of
maximal impulse; S1, first heart sound; S2, second heart sound; S4, fourth heart sound; SVC, superior vena cava; TEE,
transesophageal echocardiography; V1, chest ECG lead 1.