|
|
| Line 23: |
Line 23: |
| *[[Left ventricular function]] can be assessed by determining the [[apical impulse]]. | | *[[Left ventricular function]] can be assessed by determining the [[apical impulse]]. |
| *A normal or hyperdynamic [[apical impulse]] suggests good [[ejection fraction]] and primary [[mitral regurgitation]]. | | *A normal or hyperdynamic [[apical impulse]] suggests good [[ejection fraction]] and primary [[mitral regurgitation]]. |
| *A displaced and sustained [[apical impulse]] suggests decreased [[ejection fraction]] and chronic and severe [[mitral regurgitation]].
| |
| |
| |
| *The [[holosystolic murmur]] can be best heard over the left third and fourth intercostal spaces and along the sternal border.
| |
| *When the shunt becomes reversed ([[Eisenmenger's syndrome]]), the murmur may be absent and S<sub>2</sub> can become markedly accentuated and single.
| |
| |
| |
| *Severe TR has been documented to mimic some hemodynamic findings in [[constrictive pericarditis]], with [[right heart catheterization]] demonstrating a constrictive physiology. [[Echocardiography]], CT thorax, and [[cardiac MRI]] are useful for ruling out [[pericardium|pericardial]] pathology.
| |
| |}
| |
|
| |
| {| border="1"
| |
| |- style="padding: 0 5px; font-size: 100%; " align="center"
| |
| |'''Tricuspid Regurgitation'''
| |
| |'''Mitral Regurgitation'''
| |
| |'''VSD'''
| |
| |'''Constrictive Pericarditis'''<ref name="pmid24995118" />
| |
| |- style="font-size: 100; padding: 0 5px;"
| |
| |
| |
| *Can be best heard over the fourth intercostal area at [[left sternal border]].
| |
| *The intensity can be accentuated following [[inspiration]] ([[Carvallo's sign]]) due to increased regurgitant flow in [[right ventricular]] volume.
| |
| *Tricuspid regurgitation is most often secondary to [[pulmonary hypertension]].
| |
| *Primary tricuspid regurgitation is less common and can be due to bacterial [[endocarditis]] following [[IV drug use]], [[Ebstein's anomaly]], [[carcinoid disease]], or prior [[right ventricular infarction]].
| |
| |
| |
| *The [[murmur]] in [[mitral regurgitation]] is high pitched and best heard at the [[apex]] with diaphragm of the [[stethoscope]] with patient in the lateral decubitus position.
| |
| *[[Left ventricular function]] can be assessed by determining the [[apical impulse]].
| |
| *A normal or hyperdynamic [[apical impulse]] suggests good [[ejection fraction]] and primary [[mitral regurgitation]].
| |
| *A displaced and sustained [[apical impulse]] suggests decreased [[ejection fraction]] and chronic and severe [[mitral regurgitation]]. | | *A displaced and sustained [[apical impulse]] suggests decreased [[ejection fraction]] and chronic and severe [[mitral regurgitation]]. |
| | | | | |
| Line 54: |
Line 30: |
| *Severe TR has been documented to mimic some hemodynamic findings in [[constrictive pericarditis]], with [[right heart catheterization]] demonstrating a constrictive physiology. [[Echocardiography]], CT thorax, and [[cardiac MRI]] are useful for ruling out [[pericardium|pericardial]] pathology. | | *Severe TR has been documented to mimic some hemodynamic findings in [[constrictive pericarditis]], with [[right heart catheterization]] demonstrating a constrictive physiology. [[Echocardiography]], CT thorax, and [[cardiac MRI]] are useful for ruling out [[pericardium|pericardial]] pathology. |
| |}<br /> | | |}<br /> |
| {| class="wikitable"
| |
| ! rowspan="2" |Diseases
| |
| ! rowspan="2" |History
| |
| ! rowspan="2" |Symptoms
| |
| ! rowspan="2" |Physical Examination
| |
| ! rowspan="2" |Murmur
| |
| ! colspan="4" |Diagnosis
| |
| ! rowspan="2" |Other Findings
| |
| |- style="background: #DCDCDC; padding: 5px; text-align: center;"
| |
| !ECG
| |
| !CXR
| |
| !Echocardiogram
| |
| !Cardiac Catheterization
| |
| |-
| |
| | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Mitral Stenosis]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Age ( Mitral annular calcification in older patients)
| |
|
| |
| *[[Rheumatic fever]]
| |
|
| |
| *[[Endocarditis]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[Dyspnea on exertion]]
| |
|
| |
| *[[Paroxysmal nocturnal dyspnea]]
| |
|
| |
| *[[Orthopnea]]
| |
|
| |
| *New onset [[atrial fibrillation]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Mitral facies
| |
|
| |
| *Heart murmur
| |
|
| |
| *[[JVD|Jugular vein distension]]
| |
|
| |
| *Apical impulse displaced laterally or not palpable
| |
|
| |
| *Diastolic thrill at the apex
| |
|
| |
| *Signs of heart failure in severe cases
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Diastolic murmur
| |
|
| |
| *Low pitched
| |
|
| |
| *Opening snap followed by decrescendo-crescendo rumbling murmur
| |
|
| |
| *Best heard with the bell of the stethoscope at apex at end-expiration in left lateral decubitus position
| |
|
| |
| *Intensity increases after a [[valsalva maneuver]], after exercise and after increased after load (eg., squatting, isometric hand grip)
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[P mitrale]]
| |
| *[[Atrial fibrillation]]: No P waves and irregularly irregular rhythm
| |
|
| |
| *[[Right axis deviation]]
| |
|
| |
| *Right ventricular hypertropy: Dominant R wave in V1 and V2
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Straightening of the left border of the heart suggestive of enlargement of the [[left atrium]]
| |
|
| |
| *Double right heart border (Enlarged left atrium and normal right atrium)
| |
|
| |
| *Prominent left atrial appendage
| |
|
| |
| *Splaying of [[Carina|subcarinal angle]] (>120 degrees)
| |
|
| |
| *Calcification of [[mitral valve]]
| |
|
| |
| *[[Kerley B lines]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Reduced valve leaflet mobility
| |
|
| |
| *Valve calcification
| |
|
| |
| *Doming of mitral valve
| |
|
| |
| *Valve thickening
| |
| *Enlargement of left atrium
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Right heart catheterization:'''
| |
| *[[Pulmonary capillary wedge pressure]] (left atrial pressure)
| |
|
| |
| '''Left heart catheterization:'''
| |
|
| |
| *Pressures in left ventricle
| |
|
| |
| *Determines the gradient between the left and right atrium during ventricular diastole (marker of the severity of mitral stenosis)
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[Hemoptysis]] ([[heart failure]])
| |
|
| |
| *[[Ortner's syndrome]]
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Mitral Regurgitation]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[CAD]]
| |
|
| |
| *[[MI]]
| |
|
| |
| *[[Rheumatic fever]]
| |
|
| |
| *[[Endocarditis]]
| |
|
| |
| *[[Mitral valve prolapse]]
| |
|
| |
| *[[Cardiomyopathy]]
| |
|
| |
| *[[Radiation therapy]]
| |
|
| |
| *Trauma
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[Palpitations]]
| |
|
| |
| *Symptoms of heart failure in severe cases
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Palpation'''
| |
| *Brisk carotid upstroke and hyperdymanic carotid impulse on palpation
| |
|
| |
| *Apical impulse is displaced to left
| |
|
| |
| *S3 and a palpable thrill
| |
|
| |
| '''Auscultation'''
| |
|
| |
| *Murmur
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[Holosystolic murmur]]
| |
|
| |
| *High pitched, blowing
| |
|
| |
| *Radiates to axilla
| |
|
| |
| *Best heard with the diaphragm of the stethoscope at apex in left lateral [[decubitus]] position
| |
|
| |
| *Intensity increases with hand grip or squatting
| |
|
| |
| *Decrease in intensity on standing or [[valsalva maneuver]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[P mitrale]] in lead II
| |
| *Increased QRS voltage
| |
| *[[Right axis deviation]]
| |
| *[[Atrial fibrillation]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Acute MR'''
| |
| *[[Kerley B lines]]
| |
| *No enlargement of cardiac silhouette
| |
|
| |
| '''Chronic MR'''
| |
|
| |
| *Enlarged cardiac silhouette
| |
| *Straightening of left heart border
| |
| *Splaying of subcarinal angle
| |
| *Calcification of mitral annulus
| |
| *Double right heart border
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Enlargement of left atrium and ventricle
| |
| *Identify valve abnormality
| |
| *Valve calcification
| |
| *Severity of regurgitation
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Grading of MR is done with left ventriculography
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Decompensated and acute MR may lead to [[heart failure]]
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Atrial septal defect]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Frequent respiratory or lung infections
| |
| *[[Dyspnea]]
| |
| *Tiring when feeding (Infants)
| |
| *Shortness of breath on exertion
| |
| *[[Palpitations]]
| |
| *Swelling of feet
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[Shortness of breath]]
| |
| *[[Fatigue]]
| |
| *[[Failure to thrive]]
| |
| *Swelling of feet and abdomen ([[Right heart failure]])
| |
| *[[Palpitations]]
| |
| *Respiratory infections
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Inspection'''
| |
| *Precordial bulge
| |
| *Precordial lift
| |
|
| |
| '''Palpation'''
| |
|
| |
| *Right ventricular impulse
| |
| *Pulmonary artery pulsations
| |
| *Thrill
| |
|
| |
| '''Auscultation'''
| |
|
| |
| *Murmur
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Midsystolic (ejection systolic) murmur
| |
|
| |
| *Widely split, fixed S2
| |
|
| |
| *Upper left sternal border
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Normal
| |
| *Prolonged PR interval
| |
| *[[Right bundle branch block]]
| |
| *ECG findings varies according to the underlying type of ASD
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Increased pulmonary markings
| |
| *[[Cardiomegaly]]
| |
| *Triangular appearance of heart
| |
| *Schimitar sign
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Gold standard test for diagnosis of atrial septal defect (for more information click [[Atrial septal defect echocardiography]])
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Defect size
| |
| *Pulmonary venous return
| |
| *[[Pulmonary vascular resistance]]
| |
| *[[Pulmonary artery hypertension]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Asymptomatic until later part of their life
| |
| *May be associated with [[migraine with aura]]
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Atrial myxoma|Left Atrial Myxoma]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *[[Dyspnea]]
| |
| *[[Orthopnea]]
| |
| *[[Pulmonary edema]]
| |
| *Hyperpigmentation of skin and endocrine activity
| |
| *Cerebral [[embolism]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Symptoms may mimic mitral stenosis
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Skin'''
| |
| *Signs of an embolic phenomenon
| |
| *[[Raynaud's phenomenon]]
| |
| *Swelling
| |
| *Clubbing
| |
|
| |
| '''Auscultation:'''
| |
|
| |
| *Lung: Fine crepitations
| |
|
| |
| *Heart: Characteristic "tumor plop"
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Early diastolic sound as "tumor plop"
| |
|
| |
| *Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Often normal
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Often normal
| |
|
| |
| '''Rare findings:'''
| |
|
| |
| *[[cardiomegaly]]
| |
| *Left atrial enlargement
| |
| *tumor calcification etc.,
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Initial and most useful diagnostic study
| |
| *For more information click [[Myxoma echocardiography or ultrasound]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Useful to detect vascular supply of the tumor by the coronary arteries
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Associated with Carney complex (genetic predisposition)
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Prosthetic Valve Obstruction
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *History of valve replacement
| |
| *Systemic embolism
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Shortness of breath
| |
| *Fatigue
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Ausculation'''
| |
| Muffling of murmur
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Muffling or disappearance of prosthetic sounds
| |
|
| |
| *Appearance of new regurgitant or obstructive murmur
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Degree of stenosis
| |
| *Assess thrombus size and location
| |
| *Differentiate between thrombus, [[pannus]] and vegetations
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Causes:
| |
|
| |
| *Thrombus
| |
| *Pannus formation
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Cor Triatriatum]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Dyspnea on exertion
| |
| *Recent onset of [[congestive heart failure]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Dsypnea on exertion
| |
| *Orthopnea
| |
| *Tachypnea
| |
| *Palpitations
| |
| *Growth failure
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation'''
| |
| *Murmur
| |
|
| |
| '''Other findings'''
| |
|
| |
| *Signs of heart failure
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Diastolic murmur with loud P2
| |
|
| |
| *No opening snap or a loud S1
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Non specific but may have
| |
|
| |
| *[[Right axis deviation]]
| |
| *Right atrial enlargement
| |
| *[[Right ventricular hypertrophy]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Normal cardiac silhouette
| |
| *Hemodynamic changes similar to mitral stenosis (non specific findings)
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Direct visualization of membrane through the atrium
| |
| *+/- visualization of accessory chamber
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Normal left ventricular hemodynamic profile with a trans atrial gradient
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Types
| |
|
| |
| *Cor triatriatum sinistrum
| |
| *Cor triatriatum dextrum
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Congenital Mitral Stenosis
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Respiratory distress shortly after birth
| |
| *Recurrent severe pulmonary infections
| |
| *Other associated congenital cardiovascular anamolies
| |
| *[[Atrial fibrillation]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Infants:'''
| |
|
| |
| *Exhaustion and sweating on feeding
| |
| *Rapid breathing
| |
| *[[Failure to thrive]]
| |
| *Pulmonary infections
| |
| *Chronic cough
| |
|
| |
| '''Older patients:'''
| |
|
| |
| *Dyspnea
| |
| *Orthopnea
| |
| *Paroxysmal nocturnal dyspnea
| |
| *Peripheral edema
| |
| *Fatigue
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation'''
| |
| *Murmur
| |
|
| |
| '''Other findings'''
| |
|
| |
| *Signs of heart failure
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Mild-Moderate'''
| |
| *Loud S1
| |
|
| |
| *Loud P2
| |
|
| |
| *Low frequency diastolic murmur best heard at the apex
| |
|
| |
| '''Severe'''
| |
|
| |
| *Soft S1
| |
|
| |
| *Loud pulmonic component of S2 with minimal respiratory splitting of S2
| |
|
| |
| *Holodiastolic murmur with presystolic accentuation best heard at the apex
| |
|
| |
| *Early diastolic murmur of pulmonic valve regurgitation
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Sharp P waves in leads I and II
| |
| *Inversion of P wave in lead III
| |
| *Marked Q waves in leads II and III
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Left atrial dilation
| |
| *Moderate enlargement of right heart
| |
| *Pulmonary venous congestion
| |
| *Esophageal compression
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Reduced valve leaflet mobility
| |
| *Left atrial size
| |
| *Severity of mitral stenosis
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Very rare condition
| |
| |-
| |
| | colspan="10" |
| |
| |-
| |
| | style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Supravalvular Ring Mitral Stenosis
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Other associated congenital heart defects
| |
| *Fatigue
| |
| *Frequent respiratory infections
| |
| *Failure to thrive
| |
| *Poor feeding
| |
| *Precocious congestive heart failure
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Shortness of breath
| |
|
| |
| *Tachypnea
| |
| *Dyspnea
| |
| *Nocturnal cough
| |
| *Heamoptysis
| |
| *[[Syncope]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation:'''
| |
| Lungs: Fine, crepitant rales and rhonchi or wheezes may be present
| |
|
| |
| Heart: Murmur
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *An apical mid diastolic murmur with presystolic accentuation
| |
|
| |
| *No opening snap
| |
|
| |
| *The murmur is more prominent if associated with [[VSD]] or [[PDA]]
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Left atrial and ventricular enlargement
| |
| *Alveolar edema
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Supramitral ring''':
| |
|
| |
| *Associated with normal mitral valve apparatus
| |
|
| |
| '''Intramitral ring:'''
| |
|
| |
| *Hypomobility of the posterior leaflet
| |
| *Reduced interpapillary muscle distance
| |
| *Reduced chordal length
| |
| *Dominant papillary muscle
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| *Hypoplastic mitral annulus
| |
|
| |
| (Difficult to visualize membrane <1mm in size)
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
| |
| *Persistently elevated pulmonary venous pressures
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| *Increased pulmonary artery pressure
| |
| | style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Types'''
| |
| *Supramitral
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| *Intramitral
| |
|
| |
| It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister.
| |
|
| |
| *Intramitral type is associated with shone complex
| |
| |}
| |
| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
