Heart Murmurs Made Easy - Aortic and Mitral Heart Murmurs explained - Cardiology - Dr Gill

hello and welcome back to the channel my name is dr james gill and you joined us here to deal with my arch nemesis we're going to deal with no not bob he'll be helping her shortly but cardiology cardiology i'm very good with the practical but at medical school i did struggle with some of the theory that has meant that i've got some slightly unique ways of remembering some of these bits so hopefully they will help some of you at home get a better understanding of what's going on with that red pumpy thing inside your chest so whilst the core of the information today has been taken from mcleod's clinical examination um mcleod's is very much a full fat meal there's a lot of work involved with it and sometimes on the wards you want something a little bit trimmer so we've got a copy of clinical examination essentials from student consult here today that we're going to give away so wait until the end of the video and while i tell you how you can perhaps get your hands on one of these smaller concise textbooks so if we're going to deal with murmurs i suppose the first thing we need to do is find out what actually is a murmur well when blood is passing through well actually let's move away from blood for a second let's do straightforward physics when you have a tube and fluid air something is moving or flowing down that tube as long as we have laminar flow so always going forwards we tend to get relatively little noise a whooshing if anything so it's the same as cars going by you on a road however if we put something in that tube for example from cardiology if we were to put a plaque there for example or maybe thicken the valve so that we no longer get this uninterrupted laminar flow we get turbulent flow then we'll hear we get extra noises here it's the same as if on the road there's a sudden speed bump that everyone has to go over it changes the pattern of the fluid dynamics so we're getting extra noises and that's what we're going to be looking at with cardiology murmurs where something has affected the flow of the blood over the heart valve and thus changed the sound of the flow or perhaps the sound of the valve closing so that's what a murmur is but it looks like there's still a lot for us to unpack there particularly if we're going to talk about hot valves opening and closing so there are four valves in the heart we've got the aortic valve the pulmonary valve the mitral valve and the tricuspid valve so if we just do a quick tour of the heart blood comes in from the atrium through the tricuspid valve and will be ejected from the right ventricle out through the pulmonary valve blood will then re-enter into the left atrium from the lungs and it'll pass from the left atrium through the mitral valve into the ventricle the left ventricle will then inject that blood up through the aortic valve and then out to the body and when it comes to clinically examining the chest or the precordium we're going to listen to those heart valves in the following order aortic pulmonary tricuspid and mitral and some people will use the mnemonic apes to man as the mnemonic to remember a p t m so in terms of auscultation of precordium we need to listen to the aortic region which is the right upper sternal border we need to listen to the pulmonary region which is the left upper sternal border we want to listen to the tricuspid region which is the left lower sternal border and then we also want to cover over the the apex beat which is going to be over the fifth intercostal space mid clavicular line so that clinical examination order over the aortic area the pulmonary area the tricuspid area and the mitral areas are different both from the order of the closure of the valves and also the positions of the heart valves in the actual organ itself so why are we listening in these odd locations we're going to go back to that concept of murmurs turbulent or laminar flow and it's all about sound which is why cardiology is you know big stethoscope type medicine with the aortic pulmonary tricuspid and mitral areas of auscultation because that's the crucial bit we're listening to the direction in which the sound goes so the aortic valve auscultation region is actually going to be quite far displaced from the anatomical location of the valve because we're talking about sound propagation within the body similarly that's why with an aortic stenosis murmur the sound will propagate up the carotid artery so we'll get radiation of that murmur to the carotids okay so that touches on some of the weird and wonderfulness that we are going to be explaining i suppose we need to look at the order of the heart sounds now our classic love dub lub dub lub dub so that lub is actually called the s1 heart sound and dub is the s2 so the s1 sound or our lub noise this is the ventricular systole and it's heard when the av valves or the mitral and tricuspid valves close at the same time the aortic and pulmonary the semilunar valves will open but that's not going to give us a noise in the vast majority of cases our dub noise is when the aortic and pulmonary our semilunar valves close and by comparison the tricuspid and mitral are av valves open now i'm a very visual chap and when i was younger i spent a lot of time building computers and i was always bothered about the graphics card i'm a big geforce fan nvidia all the way however didn't really give a monkeys about the sound card and i was quite happy to have the cheapest one i'm just not an audiophile i'm not wired that way and that's probably one of the reasons why i struggled to get my ear in as it were with cardiac murmurs so there's a simple way that you can help yourself with that at the beginning of your examination by feeling the radial or carotid if you wish pulse every time you're feeling a pulse there that's obviously ventricular contraction ventricular systole and that's when the av valves the miter and tricuspid are closing and we know when we can't feel the pulse but we're hearing the dub on the chest that's our s2 and that's when the semilunar valves the aortic and pulmonary valves are closing so with that we know that when we can feel the pulse what we're going to be hearing is our s1 sounds so our tricuspid and mitral valve sound so that should help guide us much more in our examination findings with regard to what we're hearing so we've got four heart valve pathologies that we're going to talk about let's start off with what i feel is the easiest aortic stenosis so this is quite a comparatively common murmur and it's very easy to hear on the chest possibly one of the reasons why it's so common and easy to hear is actually one of the causative factors of aortic stenosis is age you know it can be picked up in people as young as 40 and 50. and it's just that valve is becoming calcified or thickened it's just used to being well used so much now in terms of our classifications we say that this is an injection systolic murmur so what that means is we're getting the s1 sound and it's coming afterwards so we'll change from having our lub dub lub dub to lub sound love sound and actually what we're going to find with aortic stenosis because it narrows the this area for blood to be ejected from the heart it's very much like putting your finger over a hose pipe you've got a nice wide bore of fluid coming out of the hose pipe you put your thumb over it becomes much sharper much higher note so we now get rather than love dub we get love whoosh love and that's what you're going to hear when you listen over the aortic region you'll hear very classic love love but if you're not absolutely certain as we say certain murmurs have certain radiation so we can confirm what we're hearing by with an aortic stenosis that whoosh noise will radiate up the carotids so by by getting the patient to hold their breath if we can we can put the stethoscope on the neck and listen over the carotid where we should hear the same whoosh whoosh whoosh noise going up that carotid because it's simply being transmitted in that tube of fluid or tube of blood now we've mentioned that age is going to be a prime cause of aortic stenosis but there's a couple of other things that we might see as well so we may find an aortic stenotic murmur in cardiomyopathy where we've got changes to the actual tissue of the heart we may however see that same noise love whoosh love wush in sepsis so with sepsis obviously the heart is going 10 to the dozen and that's where we're getting a flow murmur i actually have a flow murmur myself so when teaching the students if i go for a run up the stairs i can get my heart rate up and that will allow them to hear this non-pathological benign whooshing noise in my chest which because it's a left-sided valve pathologies if i breathe out we actually get an increased volume to that but this flow moment is entirely benign and it's simply because i like to think certainly pre pre-lockdown i was relatively fit so we know that if we can feel the pulse that's s1 we know that we've got an ejection systolic murmur so coming after the s1 we know that an aortic stenosis is going to radiate to the carotids and it's going to be louder in expiration and we know that it's going to make a whoosh noise however that's an awful lot to remember when you're doing a cardiovascular history as with any history don't forget that about 80 90 of your diagnosis is going to come from your history and patients with aortic stenosis tend to be sad now i don't mean that they mean they're unhappy what i mean is that they're likely going to have syncope they're likely going to have angina and they're likely going to have disney shortness of breath as well so if they've got those three things that's automatically going to start me thinking am i going to find aortic stenosis when i listen to this patient's chest now small clarification with that syncope that's exercise induced so they try and do exercise and they feel light-headed and or collapse this is not a collapse after they've done exercise now i've said that aortic stenosis is relatively common so unsurprisingly there's quite a few famous people that have had aotic stenosis one of those is arnold schwarzenegger we think and it's very interesting if you have a look at the procedure that he had with his valvular pathology so he had what's called a ros procedure so if we're going to start off by having a look at the heart itself we can see the pulmonary valve is tricuspid as is the aortic valve this is why arnold schwarzenegger was able to have a roth procedure where his healthy pulmonary valve was removed and was used to replace his diseased aortic valve with a cadaveric valve replacing his previously healthy pulmonary valve one of the main reasons being for this choice is that he wanted to be able to continue to exercise and act and generally be arnold schwarzenegger which would be much more difficult if he'd had a metal prosthetic valve now talking about a metal prosthetic valve is a wonderful little segway there because when we're listening to murmurs we need to grade them so we can have a grade one murmur which is basically a professor of cardiology is going to struggle but will be able to hear it all the way through to a grade six murmur where a medical student will be able to hear it at the end of the bed get this without even using a stethoscope and that is most likely what we would see if someone had a metallic valve often you'll hear that coming from the end of the bed as you're talking to the patient because you're hearing that valve open and snap close open and snap closed so that pretty much wraps up our aortic stenosis let's stay with the aortic valve and move on to aortic regurgitation so if we just think about that if we you know think about regurgitation we're kind of going to bring back a lot of people associate the word regurgitation with vomiting you know you could regurgitate up food it's not quite the same thing but nevertheless that's where we have that mental image and that's important to keep in mind because when we're talking about regurgitation of flow of blood we're talking about blood going through the valve the wrong way so this is a diastolic murmur so we're going to hear this before the s1 sound and after the s2 so we'll have noise lub dub noise lub dub so health warning here i'm being a little bit tenuous but again bear with my mind so if we're going to think on a jurassic park-esque theme a raptor could have regurgitation and that's important because the sound that we hear with aortic stenosis we have a whooshing noise with aortic regurgitation we're getting a r r [Music] yes i know these things are weird but trust me it works and you'll think i'm being completely daft and you'll listen to somebody's chest and you'll think hold on regurgitation raptors roaring i've got it it's aortic regurgitation again very visual person and these are the ways that things stuck in my head when i did this revision so where are we going to hear this diastolic rolling of the r well it's loudest over the apex of the heart down here so thinking about that we've got a different location even though we've said we are listening classically to the aortic valve over the second intercostal space by the right sternal edge now this highlights what we're thinking about with blood flow so with aortic stenosis we've got flow radiating out and up to the carotids with regurgitation we've got flow going the wrong way are now radiating down toward the apex so potential causes of aortic regurgitation could be infective endocarditis something that's directly affecting the valve or possibly a connective tissue disorder such as marfan's disease where everything is not quite as tight as it should be so if we're thinking that the valve closes but can't hold valve because essentially it's a bit floppy or the ring that holds valve in places extended a bit again because things are floppy you can see how that might regurgitate through so if we want to talk about famous people uh with marfans ma fans is classically someone who's quite tall thin will have a high arched palate and can have an arm span greater than their height and a chap who'd be very familiar to a lot of americans who would be tall thin and very famous was abraham lincoln who was thought to have marfans so would have been at risk from aortic regurgitation another very famous person but someone we don't have quite the same direct connection to who was thought to have martha fans was julius caesar so there you go there's something for your pub quiz when uh the world reopens after covid so let's move to the other side of the heart so we've gone from aortic pathologies to mitral pathologies and let's return to our stenosis so with mitral stenosis in contrast to the aortic stenosis here we have a mid diastolic murmur whereas our aortic stenosis was a systolic murmur what that essentially means is a mid diastolic murmur we're going to get it between our lub and our dub noise so we can actually sometimes hear our s1 odd lub noise increase in volume as an extra hint to help us get our ears tuned into what we're listening to now i don't have a good um thing to listen to or a good sound like our aortic stenosis whoosh or our aortic regurgitation rares however what we do have is a simon garfunkel murmur i i'm sorry what a simon and garfunkel mama have i gone completely tapped in the head well yes but no um so one of the things you don't hear with a mid diastolic murmur a mitral stenosis is the sound of silence so we don't have that love silent dub lub silence dub as we would expect instead we're getting love stub love stub lub stub love that middle emptiness has now been filled by this turbulent flow now this mitral stenosis may cause this snap an increased volume on our s1 because the changes to the valve there so we may actually get lub dub lub dub lub dub we get that increased prominence for our s1 now there's not really any radiations with mitral stenosis however we do have a classic position where we're going to listen to it and that's over the apex and for your clinical examinations this is where we'd expect to change the stethoscope from the diaphragm to the bell and roll the patient over so when it comes to auscultating murmurs of mitral stenosis we want to flip over to using the the bell or rotate the stethoscope over roll the patient over into the left lateral position and again we're going to listen fifth intercostal space mid clavicular line now whilst there might not be any radiation to help us we may see other changes the patient and they may have a malar flow so reddening over the cheeks and this is due to increased levels of co2 because rather than blood going out where it should do that blood goes out but then comes back into the heart because that regurgitation our causes of mitral stenosis are again going to be infective endocarditis because we've got things growing on the valve there but we can also see it in autoimmune conditions such as rheumatoid arthritis and in a particularly classic case for medical school but in a rather unfortunately rare scenario we can get mitral stenosis due to what's called an atrial mexoma where you've got a small tumor inside the atria which will give a classic plop noise when you're listening to the s1 and s2 so you may end up with lub love dub plop dub unfortunately it's something i've never heard on the wards before but one day i hope to hear it myself just because it's one of those you know defining things about medical school i mean we've talked about endocarditis as several potential causes for these valve issues realistically most doctors will never come across a lot of the pathological features of endocarditis but i am i'm not sure if the word is pleased but i can say that i have seen a case of endocarditis with the classic medical school features of splinter hemorrhages oslo's notes and janeway lesions and when we diagnose that chap subsequently it felt that most junior doctors in the hospital obviously asking his permission came to see if they could have a listen to his heart and to look at his fingers so i put that atrial mixoma in that list of things that i would like to clinically tick off my formal education list if you will so one of the other causes of mitral stenosis is rheumatic fever that's where it's very rare now because we have antibiotics but it was classically seen where an untreated streptococcal throat would then cause an autoimmune reaction damaging the heart valve now bill paxton staying with the idea of trying to talk about famous people with valve issues he is thought to have had mitral stenosis because he did have rheumatic fever as a child and he went for heart valve surgery unfortunately died from a post-operative complication but a regrettable story but we've still got somebody that we can pin our mental hats on there to envisage a person with it so in terms of those famous people so far we've got arnold schwarzenegger with his aortic stenosis we've got abraham lincoln with his aortic regurgitation and we've got bill paxton with his mitral stenosis but yes it does feel like i'm scraping the barrel but again i'm a visual guy and i need other ways of hawking this information in my brain okay so final um four of the major murmurs so we're now going to do mitral regurgitation so again as we've seen um before we're going to flip this with aortic regurgitation we had a diastolic murmur with mitral regurgitation we've got a systolic murmur but it's not just a systolic murmur it's a pan-systolic murmur so you're going to hear it right the way across our s1 all the way up to the s2 sound so with mitral stenosis we're going to get um our lub dub change more to a lab again that s1 is going to be much louder hence the lab these are much more granular ways of well certainly reproducing the murmurs but again it lets me feel the murmur with my mouth by making the noises so again helping me to keep those in my head so really pushing the the barrel out with our noises when it comes to mitral regurgitation it's a very cold murmur yes i'm doing another tenuous link that's because the sound that we're classically going to hear with the mitral regurgitation is with it being pan-systolic we're not getting our lub and our dub noises anymore we're more likely going to get br right the way through our um both sounds replacing it with just one long noise unlike mitral stenosis where there wasn't any good radiation this time with mitral regurgitation we listen over the apex but we're going to hear the sound radiating up into the axilla so we've got a little bit more physical evidence to support our murmur diagnosis here and unlike mitral stenosis we're still going to be using the diaphragm over this region we can however force that burr noise to increase in volume by getting the patient to squat down increasing the intrathoracic pressure another way that we can do that is with the valsalva maneuver so getting the patient to take their thumb and essentially blow on it in doing so it increases the thoracic pressure and we're going to get an increased cardiac return so we're going to get an increased flow of blood over that stenotic valve increasing that br noise in the same way that aortic regurgitation could uh be as a result of marfan's again we've got another regurgitation so muffins is a another reasonable suggestion but there's perhaps a couple of other things that are more clinically relevant so heart valve replacement can of the mitral valve can end up causing mitral stenosis we can have problems where we've actually got catastrophic damage in the heart one of the possible causes of a mitral valve regurgitation is dressless syndrome which is after a myocardial infarction where damage to the heart muscle causes rupture of these papillary muscles allowing the valve to flip the wrong way around allowing regurgitation and yet again there's also infective endocarditis as another possible cause but that tends to be only in the most acute phase so that pretty much wraps up our murmurs overview so just to do that just to make sure we've got that tactile nature of the sound again so aortic stenosis we've got a um an ejection systolic moment going whoosh with our aortic regurgitation we've got the raptors prowling around going lub dub lub dub lub with our mitral regurgitation we've got a mid diastolic murmur giving us a absence of silence so simon and garfunkel murmur and finally we've got our mitral regurgitation so giving us complete loss of s1 and s2 for a pan systolic murmur burr right the way through i don't mind making a fool of myself if it helps the students remember these things and i think that's the crucial thing here these videos are for yourselves to help improve your knowledge in terms of simple ways of remembering things aortic stenosis you are sad if you've got aotic stenosis i.e you've got syncope angina and disney by comparison in the history of a patient with aortic regurgitation doesn't work quite well so we say they has regurgitation slightly butchering the english language there because a patient may complain of features of heart failure so shortness of breath swelling to the ankles difficulty with fatigue they may have angina and shortness of breath so the patient has aortic regurgitation with mitral stenosis chaps get mitral stenosis so the patient may present with a cough again features of heart failure angina palpitations and possibly shortness of breath to complete our quartet mitral regurgitation again i'm really straining here but you get a high definition pie with mitral regurgitation again heart failure or possibly fatigue dyspnea and they also have palpitations and as mentioned one of the main causes here they may have had or tell you about previous infective endocarditis okay well i think that's probably a good opportunity to bring things to a close before it gets even dafter so if you want a chance to win uh clinical examination essentials please like the video make sure you've subscribed to us here and drop us a comment down below you know this has been a slightly different approach in terms of teaching styles so tell me what you thought went well and what you thought we could improve on this video i will enter your raffle to try and win this copy to you and yes we'll post it worldwide on that note take care have a good one i'll see you guys around cheerio you