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https://www.mayoclinic.org/diseases-conditions/mitral-valve-regurgitation/symptoms-causes/syc-20350178

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Overview

Mitral valve regurgitation - also called mitral regurgitation, mitral insufficiency or mitral incompetence - is a condition in which your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. If the mitral valve regurgitation is significant, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.

Video: Mitral valve regurgitation

Treatment of mitral valve regurgitation depends on how severe your condition is, whether it's getting worse and whether you have symptoms. For mild leakage, treatment is usually not necessary.

You may need heart surgery to repair or replace the valve for severe leakage or regurgitation. Left untreated, severe mitral valve regurgitation can cause heart failure or heart rhythm problems (arrhythmias). Even people without symptoms may need to be evaluated by a cardiologist and surgeon trained in mitral valve disease to determine whether early intervention may be beneficial.

Symptoms

Some people with mitral valve disease might not experience symptoms for many years. Signs and symptoms of mitral valve regurgitation, which depend on its severity and how quickly the condition develops, can include:

Abnormal heart sound (heart murmur) heard through a stethoscope

Shortness of breath (dyspnea), especially when you have been very active or when you lie down

Fatigue

Heart palpitations - sensations of a rapid, fluttering heartbeat

Swollen feet or ankles

Mitral valve regurgitation is often mild and progresses slowly. You may have no symptoms for many years and be unaware that you have this condition, and it might not progress.

Your doctor might first suspect you have mitral valve regurgitation upon detecting a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms.

When to see a doctor

If your doctor hears a heart murmur when listening to your heart with a stethoscope, he or she may recommend that you visit a cardiologist and get an echocardiogram. If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away. Sometimes the first indications are actually those of mitral valve regurgitation's complications, including heart failure, a condition in which your heart can't pump enough blood to meet your body's needs.

Causes

Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (leaflets or cusps) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart to your body.

In mitral valve regurgitation, the valve between the upper left heart chamber (left atrium) and the lower left heart chamber (left ventricle) doesn't close tightly, causing blood to leak backward into the left atrium (regurgitation).

Mitral valve regurgitation causes

Mitral valve regurgitation can be caused by problems with the mitral valve, also called primary mitral valve regurgitation. Diseases of the left ventricle can lead to secondary or functional mitral valve regurgitation.

Possible causes of mitral valve regurgitation include:

Mitral valve prolapse. In this condition, the mitral valve's leaflets bulge back into the left atrium during the heart's contraction. This common heart defect can prevent the mitral valve from closing tightly and lead to regurgitation.

Damaged tissue cords. Over time, the tissue cords that anchor the flaps of the mitral valve to the heart wall may stretch or tear, especially in people with mitral valve prolapse. A tear can cause leakage through the mitral valve suddenly and may require repair by heart surgery. Trauma to the chest also can rupture the cords.

Rheumatic fever. Rheumatic fever - a complication of untreated strep throat - can damage the mitral valve, leading to mitral valve regurgitation early or later in life. Rheumatic fever is now rare in the United States, but it's still common in developing countries.

Endocarditis. The mitral valve may be damaged by an infection of the lining of the heart (endocarditis) that can involve heart valves.

Heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. If the damage is extensive enough, a heart attack can cause sudden and severe mitral valve regurgitation.

Abnormality of the heart muscle (cardiomyopathy). Over time, certain conditions, such as high blood pressure, can cause your heart to work harder, gradually enlarging your heart's left ventricle. This can stretch the tissue around your mitral valve, which can lead to leakage.

Trauma. Experiencing trauma, such as in a car accident, can lead to mitral valve regurgitation.

Congenital heart defects. Some babies are born with defects in their hearts, including damaged heart valves.

Certain drugs. Prolonged use of certain medications can cause mitral valve regurgitation, such as those containing ergotamine (Cafergot, Migergot) that are used to treat migraines and other conditions.

Radiation therapy. In rare cases, radiation therapy for cancer that is focused on the chest area can lead to mitral valve regurgitation.

Atrial fibrillation. Atrial fibrillation is a common heart rhythm problem that can be a potential cause of mitral valve regurgitation.

Risk factors

Several factors can increase your risk of mitral valve regurgitation, including:

A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean you'll develop mitral valve regurgitation. A family history of valve disease also can increase risk.

A heart attack. A heart attack can damage your heart, affecting the function of the mitral valve.

Heart disease. Certain forms of heart disease, such as coronary artery disease, can lead to mitral valve regurgitation.

Use of certain medications. People who take drugs containing ergotamine (Cafergot, Migergot) and similar medicines for migraines or who take cabergoline have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold.

Infections such as endocarditis or rheumatic fever. Infections or the inflammation they cause can damage the mitral valve.

Congenital heart disease. Some people are born with an abnormal mitral valve prone to regurgitation.

Age. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve.

Complications

When it's mild, mitral valve regurgitation usually does not cause any problems. However, severe mitral valve regurgitation can lead to complications, including:

Heart failure. Heart failure results when your heart can't pump enough blood to meet your body's needs. Severe mitral valve regurgitation places an extra strain on the heart because, with blood pumping backward, there is less blood going forward with each beat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure.

Also, pressure builds in your lungs, leading to fluid accumulation, which strains the right side of the heart.

Atrial fibrillation. The stretching and enlargement of your heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of your heart beat chaotically and rapidly. Atrial fibrillation can cause blood clots, which can break loose from your heart and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain.

Pulmonary hypertension. If you have long-term untreated or improperly treated mitral regurgitation, you can develop a type of high blood pressure that affects the vessels in the lungs (pulmonary hypertension). A leaky mitral valve can increase pressure in the left atrium, which can eventually cause pulmonary hypertension. This can lead to heart failure on the right side of the heart.

Show references

1. What is heart valve disease? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/hvd. Accessed Aug. 21, 2017.

2. Mitral regurgitation. Merck Manual Professional Version. http://www.merckmanuals.com/professional/cardiovascular-disorders/valvular-disorders/mitral-regurgitation. Accessed Aug. 25, 2017.

3. Otto CM. Clinical manifestations and diagnosis of chronic mitral regurgitation. https://www.uptodate.com/contents/search. Accessed Aug. 21, 2017.

4. AskMayoExpert. Mitral regurgitation. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2017.

5. Gaasch WH. Pathophysiology of chronic mitral valve regurgitation. https://www.uptodate.com/contents/search. Accessed Aug. 21, 2017.

6. Otto CM. Acute mitral regurgitation in adults. https://www.uptodate.com/contents/search. Accessed Aug. 25, 2017.

7. Nishimura RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: Executive summary. Journal of the American College of Cardiology. 2014;63:2438.

8. What causes heart failure? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/hf/causes. Accessed Aug. 25, 2017.

9. What is atrial fibrillation? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/af. Accessed Aug. 21, 2017.

10. What is pulmonary hypertension? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/pah. Accessed Aug. 21, 2017.

11. Gaasch WH. Management of chronic primary mitral regurgitation. https://www.uptodate.com/contents/search. Accessed Aug. 24, 2017.

12. Gaasch WH. Surgical procedures for severe chronic mitral regurgitation. https://www.uptodate.com/contents/search. Accessed Aug. 21, 2017.

13. Aldea GS. Minimally invasive aortic and mitral valve surgery. https://www.uptodate.com/contents/search. Accessed Aug. 21, 2017.

14. Vernick W, et al. Robotic and minimally invasive cardiac surgery. Anesthesiology Clinics. 2013;31:299.

15. Nishimura RA, et al. Mitral valve disease - Current management and future challenges. Lancet. 2016;387:1324.

16. Ruiz CE, et al. Transcatheter therapies for the treatment of valvular and paravalvular regurgitation in acquired and congenital valvular heart disease. Journal of the American College of Cardiology. 2015;66:169.

17. What causes cardiomyopathy? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/cm/causes. Accessed Aug. 30, 2017.

18. What causes an arrhythmia? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/arr/causes. Accessed Aug. 30, 2017.

19. Riggin EA. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Aug. 30, 2017.

20. Riggin EA. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Aug. 30, 2017.

21. Riggin EA. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Aug. 30, 2017.

22. Daniels BK. Echo Information Management System. Mayo Clinic, Rochester, Minn. Sept. 13, 2017.

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Mitral valve regurgitation - Symptoms and causes

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Mitral valve regurgitation - also called mitral regurgitation, mitral insufficiency or mitral incompetence - is a condition in which your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. If the mitral valve regurgitation is significant, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.

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https://www.mayoclinic.org/diseases-conditions/mitral-valve-stenosis/symptoms-causes/syc-20353159

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Overview

Mitral valve stenosis - or mitral stenosis - is a narrowing of the heart's mitral valve. This abnormal valve doesn't open properly, blocking blood flow into the main pumping chamber of your heart (left ventricle). Mitral valve stenosis can make you tired and short of breath, among other problems.

The main cause of mitral valve stenosis is an infection called rheumatic fever, which is related to strep infections. Rheumatic fever - now rare in the United States, but still common in developing countries - can scar the mitral valve. Left untreated, mitral valve stenosis can lead to serious heart complications.
Mitral valve stenosis care at Mayo Clinic
Symptoms

You may feel fine with mitral valve stenosis, or you may have minimal symptoms for decades. Mitral valve stenosis usually progresses slowly over time. See your doctor if you develop:

Shortness of breath, especially with exertion or when you lie down

Fatigue, especially during increased physical activity

Swollen feet or legs

Heart palpitations - sensations of a rapid, fluttering heartbeat

Dizziness or fainting

Coughing up blood

Chest discomfort or chest pain

Mitral valve stenosis symptoms may appear or worsen anytime your heart rate increases, such as during exercise. An episode of rapid heartbeats may accompany these symptoms. Or they may be triggered by pregnancy or other body stress, such as an infection.

In mitral valve stenosis, pressure that builds up in the heart is then sent back to the lungs, resulting in fluid buildup (congestion) and shortness of breath.

Symptoms of mitral valve stenosis most often appear in between the ages of 15 and 40 in developed nations, but they can occur at any age - even during childhood.

Mitral valve stenosis may also produce signs that your doctor will find during your examination. These may include:

Heart murmur

Fluid buildup in the lungs

Irregular heart rhythms (arrhythmias)

When to see a doctor

Call your doctor for an immediate appointment if you develop fatigue or shortness of breath during physical activity, heart palpitations, or chest pain.

If you have been diagnosed with mitral valve stenosis but haven't had symptoms, talk to your doctor about follow-up evaluations.

Causes

Causes of mitral valve stenosis include:

Rheumatic fever. A complication of strep throat, rheumatic fever can damage the mitral valve. Rheumatic fever is the most common cause of mitral valve stenosis. It can damage the mitral valve by causing the flaps to thicken or fuse. Signs and symptoms of mitral valve stenosis might not show up for years.

Calcium deposits. As you age, calcium deposits can build up around the ring around the mitral valve (annulus), which can occasionally cause mitral valve stenosis.

Other causes. In rare cases, babies are born with a narrowed mitral valve (congenital defect) that causes problems over time. Other rare causes include radiation to the chest and some autoimmune diseases, such as lupus.

How the heart works

The heart, the center of your circulatory system, consists of four chambers. The two upper chambers (atria) receive blood. The two lower chambers (ventricles) pump blood.

Four heart valves open and close to let blood flow in only one direction through your heart. The mitral valve - which lies between the two chambers on the left side of your heart - comprises two flaps of tissue called leaflets.

The mitral valve opens when blood flows from the left atrium to the left ventricle. Then the flaps close to prevent the blood that has just passed into the left ventricle from flowing backward. A defective heart valve fails to either open or close fully.

Risk factors

Mitral valve stenosis is less common today than it once was because the most common cause, rheumatic fever, is rare in the United States. However, rheumatic fever remains a problem in developing nations.

Risk factors for mitral valve stenosis include:

History of rheumatic fever

Untreated strep infections

Complications

Like other heart valve problems, mitral valve stenosis can strain your heart and decrease blood flow. Untreated, mitral valve stenosis can lead to complications such as:

Pulmonary hypertension. This is a condition in which there's increased pressure in the arteries that carry blood from your heart to your lungs (pulmonary arteries), causing your heart to work harder.

Heart failure. A narrowed mitral valve interferes with blood flow. This can cause pressure to build in your lungs, leading to fluid accumulation. The fluid buildup strains the right side of the heart, leading to right heart failure.

When blood and fluid back up into your lungs, it can cause a condition known as pulmonary edema. This can lead to shortness of breath and, sometimes, coughing up of blood-tinged sputum.

Heart enlargement. The pressure buildup of mitral valve stenosis results in enlargement of your heart's upper left chamber (atrium).

Atrial fibrillation. The stretching and enlargement of your heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of your heart beat chaotically and too quickly.

Blood clots. Untreated atrial fibrillation can cause blood clots to form in the upper left chamber of your heart. Blood clots from your heart can break loose and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain.

Prevention

The best way to prevent mitral valve stenosis is to prevent its most common cause, rheumatic fever. You can do this by making sure you and your children see your doctor for sore throats. Untreated strep throat infections can develop into rheumatic fever. Fortunately, strep throat is usually easily treated with antibiotics.

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Mitral valve stenosis - Symptoms and causes

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Mitral valve stenosis - or mitral stenosis - is a narrowing of the heart's mitral valve. This abnormal valve doesn't open properly, blocking blood flow into the main pumping chamber of your heart (left ventricle).

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Improve Article 👀

Introduction

A heart murmur is a sound produced due to turbulent blood flow within the heart.

Heart murmurs are heard by auscultation with a stethoscope as part of the cardiovascular examination.

The cardiac cycle

The cardiac cycle refers to a series of physiological events making up a single heartbeat. The cycle involves contraction (systole) and relaxation (diastole) of the atria and ventricles to effectively pump blood.

The cardiac cycle starts with the atria and ventricles in diastole. Blood enters the right atrium (from the vena cava) and the left atrium (from the pulmonary vein). At this point, the mitral and tricuspid valves are open. This allows blood to flow freely into the right ventricle and left ventricle from the atria. The aortic and pulmonary valves are shut, which prevents an abnormal backflow of blood into the ventricles from the aorta and pulmonary artery.

The next stage of the cycle is atrial systole, contraction of the atria to finish "filling" the ventricles with blood.

Ventricular systole occurs as the ventricles contract, increasing the pressure within the ventricles. The increased pressure causes the closure of the mitral and tricuspid valves, this prevents regurgitation of blood from the ventricles into the atria.

At this point, the volume of blood within the ventricles remains constant as the aortic and pulmonary valves have not yet opened. This phase of ventricular systole is called isovolumetric contraction.

Eventually, the pressure within the ventricles exceeds the pressure in the pulmonary artery and aorta causing the pulmonary and aortic valves to open. Blood is ejected from the ventricles during ventricular ejection phase.

The ventricles then begin to relax following contraction (ventricular diastole). The drop in pressure within the ventricle causes the aortic and pulmonary valves to close, to prevent backflow (regurgitation) of blood into the ventricles.

For more information, see the Geeky Medics guide to the electrical conduction system of the heart.

Normal heart sounds

Normal heart sounds are caused by the closure of heart valves.

First heart sound (S1)

The first heart sound (S1) is caused by the closure of the mitral and tricuspid valves. It marks the start of ventricular systole, and a peripheral pulse is felt at the same time (or shortly after) S1.

Second heart sound (S2)

The second heart sound (S2) is caused by the closure of aortic and pulmonary valves. It marks the end of ventricular systole, and the start of diastole.

The pulmonary valve may close just after the aortic valve. Closure of the pulmonary valve just after the aortic valve is prolonged during inspiration, or in defects which cause more blood to be pumped out of the right ventricle.

Therefore, S2 may not always be heard as one discrete sound but may be muffled or have two discrete sounds (split S2).

Heart sounds and the cardiac cycle

How to approach heart murmurs

It is important to have a structured approach to interpreting heart murmurs. See the Geeky Medics guide to cardiovascular examination for more information on how to perform auscultation.

If a murmur is heard during auscultation, consider the following questions:

When during the cardiac cycle is the murmur heard?

What are the characteristics of the murmur? What is the intensity (Table 1)?

Is the murmur heard loudest using the bell or the diaphragm of the stethoscope?

Where is the murmur heard the loudest?

Do any manoeuvres exaggerate the murmur?

Heard loudest on inspiration or expiration?

Does the murmur radiate?

Table 1. The Levine scale for grading cardiac murmurs according to intensity. ³

A thrill is a palpable vibration caused by turbulent blood flow through a heart valve. Thrills may be felt when palpating the anterior chest wall during a cardiovascular examination.

Aortic stenosis

Aortic stenosis (AS) refers to a tightening of the aortic valve at the origin of the aorta.

Aortic stenosis is associated with an ejection systolic murmur heard loudest over the aortic valve. The murmur is described as having a 'crescendo-decrescendo' quality (it appears as diamond-shaped on a phonogram). The murmur of aortic stenosis commonly radiates to the carotid arteries.

Aetiology

Causes of aortic stenosis include:

Clinical features

Typical features of an aortic stenosis murmur include:

Other clinical features of aortic stenosis may include:

For more information, see the Geeky Medics guide to aortic stenosis examination.

Mitral regurgitation

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.

Aetiology

Mitral regurgitation can be either acute or chronic.

Causes of mitral regurgitation include:

Infective endocarditis

Acute myocardial infarction with rupture of papillary muscles

Rheumatic heart disease

Congenital defects of the mitral valve

Cardiomyopathy

Clinical features

Typical features of mitral regurgitation murmur include:

Other clinical features may include:

Displaced, hyperdynamic apex beat

Aortic regurgitation

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

Aetiology

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.

Diseases affecting the valve include:

Causes of aortic root dilatation include:

Typical clinical features

Typical features of an aortic regurgitation murmur include:

Other clinical features of aortic regurgitation may include:

Collapsing pulse (a 'water hammer pulse' with wide pulse pressure)

Displaced, hyperdynamic apex beat

Eponymous clinical signs of aortic regurgitation

There are many eponymous clinical signs associated with aortic regurgitation. These include:

Corrigan's sign: visible distention and collapse of carotid arteries in the neck

De Musset's sign: head bobbing with each heartbeat

Quincke's sign: pulsations are seen in the nail bed with each heartbeat when the nail bed is lightly compressed

Traube's sign: 'pistol shot' sound heard when stethoscope placed over the femoral artery during systole and diastole

Muller's sign: uvula pulsations are seen with each heartbeat

Mitral stenosis

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.

Aetiology

Rheumatic heart disease is the most common cause of mitral stenosis.

Other rarer causes include:

Clinical features

Typical features of a mitral stenosis murmur include:

Other clinical features of mitral stenosis may include:

Mitral valve prolapse

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.

Aetiology

Mitral valve prolapse is the most common valvular abnormality with a prevalence of approximately 5%.

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. Secondary mitral valve prolapse occurs when a 'normal' valve prolapses.

Typical clinical features

Typical features of a mitral valve prolapse murmur include:

Tricuspid regurgitation

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.

Aetiology

Causes of tricuspid regurgitation include:

Right ventricular dilatation (e.g. secondary to pulmonary stenosis or pulmonary hypertension)

Rheumatic fever

Infective endocarditis (intravenous drug users are at high risk of endocarditis affecting the tricuspid valve)

Carcinoid syndrome

Congenital (e.g. atrial septal defect, AV canal, Ebstein anomaly)

The Ebstein anomaly (i.e. congenital isolated tricuspid regurgitation) is abnormal attachment of tricuspid valve leaflets causes the tricuspid valve to displace downwards into the right ventricle.

Typical clinical features

Typical features of a tricuspid regurgitation murmur include:

Other clinical features of tricuspid regurgitation may include:

Pulmonary stenosis

Pulmonary stenosis (PS) refers to narrowing of the pulmonary valve. It is commonly associated with other congenital heart defects.

Aetiology

Causes of pulmonary stenosis include:

Typical clinical features

Typical features of a pulmonary stenosis murmur include:

Other clinical features of pulmonary stenosis may include:

Pulmonary regurgitation

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.

Aetiology

Causes of pulmonary regurgitation include:

Typical clinical features

Pulmonary regurgitation is usually asymptomatic.

Typical features of a pulmonary regurgitation murmur include:

Tricuspid stenosis

Tricuspid stenosis (TS) refers to narrowing of the tricuspid valve.

Tricuspid stenosis is associated with a soft diastolic murmur loudest at 3rd - 4th intercostal space at the left sternal edge

Aetiology

Causes of tricuspid stenosis include:

Clinical features

Typical features of a tricuspid stenosis murmur include:

Other clinical features of tricuspid stenosis may include:

Raised JVP with giant 'a waves'

Peripheral oedema, ascites

Summary

Table 2. A table summarising the key differences between different heart murmurs.

Editor

Dr Chris Jefferies

References

1. OpenStax College. Diagram describing the phases of the human cardiac cycle. License: [CC-BY]. Available from: [LINK]

2. adh30/DanielChangMD/DestinyQx. Wiggers diagram. License: [CC-BY-SA]. Available from: [LINK]

3. Innes, A, Dover, A, Fairhurst, K. Macleod's Clinical Examination - 14th Edition. Published in 2013.

4. Madhero88. Phonocardiograms from normal and abnormal heart sounds. License: [CC-BY-SA]. Available from: [LINK]

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Heart Murmurs | Clinical Features | Geeky Medics

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Improve Article 👀 A heart murmur is a sound produced due to turbulent blood flow within the heart. Heart murmurs are heard by auscultation with a stethoscope as part of the cardiovascular examination. The cardiac cycle refers to a series of physiological events making up a single heartbeat.

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https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-causes/syc-20353139

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Aortic valve stenosis - Symptoms and causes

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This type of heart valve disease reduces or blocks blood flow from the heart to the body. Know the symptoms and how it’s treated.

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Overview

Aortic valve regurgitation - or aortic regurgitation - is a condition that occurs when your heart's aortic valve doesn't close tightly. Aortic valve regurgitation allows some of the blood that was pumped out of your heart's main pumping chamber (left ventricle) to leak back into it.

The leakage may prevent your heart from efficiently pumping blood to the rest of your body. As a result, you may feel fatigued and short of breath.

Aortic valve regurgitation can develop suddenly or over decades. Once aortic valve regurgitation becomes severe, surgery is often required to repair or replace the aortic valve.
Aortic valve regurgitation care at Mayo Clinic
Symptoms

Most often, aortic valve regurgitation develops gradually, and your heart compensates for the problem. You may have no signs or symptoms for years, and you may even be unaware that you have the condition.

However, as aortic valve regurgitation worsens, signs and symptoms may include:

Fatigue and weakness, especially when you increase your activity level

Shortness of breath with exercise or when you lie down

Swollen ankles and feet

Chest pain (angina), discomfort or tightness, often increasing during exercise

Lightheadedness or fainting

Irregular pulse (arrhythmia)

Heart murmur

Sensations of a rapid, fluttering heartbeat (palpitations)

When to see a doctor

Contact your doctor right away if signs and symptoms of aortic valve regurgitation develop. Sometimes the first indications of aortic valve regurgitation are those of its major complication, heart failure. See your doctor if you have fatigue, shortness of breath, and swollen ankles and feet, which are common symptoms of heart failure.

Causes

Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (cusps or leaflets) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart and potentially impairing the ability to pump blood to your body.

In aortic valve regurgitation, the valve between the lower left heart chamber (left ventricle) and the main artery that leads to the body (aorta) doesn't close properly, which causes some blood to leak backward into the left ventricle. This forces the left ventricle to hold more blood, possibly causing it to enlarge and thicken.

At first, left ventricle enlargement helps because it maintains adequate blood flow with more force. But eventually these changes weaken the left ventricle - and your heart overall.

Any condition that damages a valve can cause regurgitation. Causes of aortic valve regurgitation include:

Congenital heart valve disease. You may have been born with an aortic valve that has only two cusps (bicuspid valve) or fused cusps rather than the normal three separate cusps. In some cases a valve may only have one cusp (unicuspid) or four cusps (quadricuspid), but this is less common.

These congenital heart defects put you at risk of developing aortic valve regurgitation at some time in your life. If you have a parent or sibling with a bicuspid valve, it increases the risk that you may have a bicuspid valve, but it can also occur if you don't have a family history of a bicuspid aortic valve.

Age-related changes to the heart. Calcium deposits can build up on the aortic valve over time, causing the aortic valve's cusps to stiffen. This can cause the aortic valve to become narrow, and it may also not close properly.

Endocarditis. The aortic valve may be damaged by endocarditis - an infection inside your heart that involves heart valves.

Rheumatic fever. Rheumatic fever - a complication of strep throat and once a common childhood illness in the United States - can damage the aortic valve. Rheumatic fever is still prevalent in developing countries but rare in the United States. Some older adults in the United States were exposed to rheumatic fever as children, although they may not have developed rheumatic heart disease.

Other diseases. Other rare conditions can enlarge the aorta and aortic valve and lead to regurgitation, including Marfan syndrome, a connective tissue disease. Some autoimmune conditions, such as lupus, also can lead to aortic valve regurgitation.

Trauma. Damage to the aorta near the site of the aortic valve, such as damage from injury to your chest or from a tear in the aorta, also can cause backward flow of blood through the valve.

Risk factors

Risk factors of aortic valve regurgitation include:

Older age

Certain heart conditions present at birth (congenital heart disease)

History of infections that can affect the heart

Certain conditions that can affect the heart, such as Marfan syndrome

Other heart valve conditions, such as aortic valve stenosis

High blood pressure

Complications

Aortic valve regurgitation can cause complications, including:

Heart failure

Infections that affect the heart, such as endocarditis

Heart rhythm abnormalities

Death

Prevention

For any heart condition, see your doctor regularly so he or she can monitor you and possibly catch aortic valve regurgitation or other heart condition before it develops or in the early stages, when it's more easily treatable. If you have been diagnosed with a leaking aortic valve (aortic valve regurgitation) or a tight aortic valve (aortic valve stenosis), you'll probably require regular echocardiograms to be sure the aortic valve regurgitation doesn't become severe.

Also, be aware of conditions that contribute to developing aortic valve regurgitation, including:

Rheumatic fever. If you have a severe sore throat, see a doctor. Untreated strep throat can lead to rheumatic fever. Fortunately, strep throat is easily treated with antibiotics.

High blood pressure. Check your blood pressure regularly. Make sure it's well-controlled to prevent aortic regurgitation.

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Aortic valve regurgitation - Symptoms and causes

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Aortic valve regurgitation - or aortic regurgitation - is a condition that occurs when your heart's aortic valve doesn't close tightly. Aortic valve regurgitation allows some of the blood that was pumped out of your heart's main pumping chamber (left ventricle) to leak back into it.

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In addition to the part of the cardiac cycle this murmur is in(Q1), this murmur can be described as a low pitched, rumbling murmur with an opening click.

Which murmur is described?

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- Basic cardiac anatomy
- Understanding of the cardiac cycle
- Recognition of normal heart sounds

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- To differentiate systolic and diastolic murmurs
- To recognise and identify the four major left-sided heart murmurs by sound and anatomical location
- To be able to relate characteristic clinical signs to underlying murmurs.

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Q1. Mitral regurgitation
Q2. 4b (axilla)
Q3a.  Typical causes are infective endocarditis, ischaemic papillary muscle dysfunction
Q3b. Pansystolic murmur heard loudest over mitral area

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Q1. A diastolic murmur (specifically mid diastolic)

Q2. Mitral Stenosis

Q3. Accentuated in (4a.) the Mitral area when rolled onto left on expiration.

Q4. Mitral stenosis is related to Rheumatic Heart Disease as rheumatic fever causes thickening of the valve leaflets.

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Q1. Aortic Stenosis
Q2. 1b (Radiates to carotids and apex)

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Aortic regurgitation

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Austin Flint Murmur- caused by the aortic regurgitation jet abutting the left ventricular endocardium in severe aortic regurgitation.

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Mechanisms of Austin Flint murmur in aortic regurgitation - following are the proposed mechanisms for the mid diastolic murmur in mitral area in severe aortic regurgitation:

1. Fluttering of the anterior mitral leaflet due to the regurgitant jet impinging on it

2. Jet can produce relative narrowing of the mitral orifice

3. Elevation of left ventricular diastolic pressure causes the mitral valve to float back to a partially closed position

4. Diastolic mitral regurgitation due to elevated left ventricular diastolic pressure [1]

The fluttering of anterior mitral leaflet and early closure due the aortic regurgitation jet has been demonstrated in a case report by cine magnetic resonance imaging [2]. Severity of aortic regurgitation was demonstrated to be more in those with Austin Flint murmur than those without the murmur [3].

A Doppler echo study did not support mechanisms 2 and 4 described above, while supporting mechanism 1 [4].
References

1. Brandão AP, Lipton MJ. Mitral diastolic regurgitation and the Austin Flint murmur. Arq Bras Cardiol. 1970 Oct;23(5):319-26.

2. Weir RA, Dargie HJ. Images in clinical medicine. Austin flint murmur. N Engl J Med. 2008 Sep 4;359(10):e11.

3. Emi S, Fukuda N, Oki T, Iuchi A, Tabata T, Kiyoshige K, Fujimoto T, Manabe K, Ito S. Genesis of the Austin Flint murmur: relation to mitral inflow and aortic regurgitant flow dynamics. J Am Coll Cardiol. 1993 May;21(6):1399-405.

4. Rahko PS. Doppler and echocardiographic characteristics of patients having an Austin Flint murmur. Circulation. 1991 Jun;83(6):1940-50.

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Mechanisms of Austin Flint murmur in aortic regurgitation - following are the proposed mechanisms for the mid diastolic murmur in mitral area in severe aortic regurgitation: Fluttering of the anterior mitral leaflet due to the regurgitant jet impinging on it Jet can produce relative narrowing of the mitral orifice Elevation

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What is likely to have caused this murmur?

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What murmur does she have?

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Another patient presents with the same murmur 2 days later. This time, a rumbling diastolic murmur is also heard at the apex. What is the name of this murmur?

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Which answer denotes where this murmur be most accentuated?

A. 1b. Carotids
B. 1a. Aortic area when sat forwards on expiration
C. 4b. Axilla when rolled onto left on expiration
D. 4a. Mitral area when rolled onto left on expiration

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63yo woman admitted for chest pain that started about 2 years ago; became progressively worse causing pain and light-headedness with exercise. Pain described as pressure in mid-chest, always with exertion, rate 7/10, attenuated by rest. Denies palpitations or syncopal episodes.

PMH: CAD, Hypertension, Hyperlipidaemia, T2DM, Depression with anxiety, BMI 35

Sx: 40 pack years, 2 beers/night, no next of kin

Examination: 3/6 systolic “crescendo-decrescendo” High-pitched ejection systolic murmur present in right 2nd IC.

Slow rising pulse

Narrow pulse pressure

Bilateral crackles in lung bases

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A low intensity, high pitched early diastolic murmur is heard at the right upper sternal border which radiates to the apex. What valve pathology is likely to be causative?

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An asymptomatic 45-year-old male comes to the clinic for his routine physical examination. Vital checkups are done and his blood pressure is 110/85 mm Hg. A mid-systolic murmur is heard at the cardiac apex, radiating laterally, occurring after a mid-systolic click. Which murmur is described?

Please comment below

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A 59 year old woman comes in with dyspnoea when walking to the shops, chest pain and palpitations with a history of a bad throat infection as a child, although she cannot remember any details. On auscultation, you hear the murmur above.

Is this a diastolic or a systolic murmur?

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What type of murmur is this?

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A 68-year-old male with a history of syphilis presents with generalized fatigue. He denies dyspnea, lower extremity edema or orthopnea. His blood pressure is 170/90 mm Hg and heart rate 80 beats per minute.

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Activist – Activists are people who learn by doing. They need to get into the action and experience what they're trying to learn and enjoy brainstorms.

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Pragmatists want to know how to put what they're learning into practice in the real world. They are practical and focused on reaching a goal.

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Where would you hear this murmur radiate to?
Which number would you pin, comment below

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Site: Where is the murmur loudest?

Character: soft? Blowing? Crescendo? Decrescendo?

Radiation: Carotids? Axilla?

Intensity: Grade of murmur?

Pitch: High? Low and grumbling? Indicates velocity.

Timing: Systolic? Diastolic?

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Where would you hear this murmur radiate to? Comment below the pin.