Andersons pediatric cardiology 1459

ClinicalAssessment
MildtomoderatechronicRHDisalmostalwaysasymptomaticinchildrenand
youngadults.EvensevereRHDmaybeassociatedwithminimalorno
symptomsintheyoung.Withoutsurgicalinterventionforthislattergroupof
patients,arapiddecompensatoryphaseoftenfollows.30

MitralRegurgitation
InthesettingofMR,symptomsoccurasincreasingleftatrialpressurecauses
pulmonaryvenoushypertensionwithsymptomsofbreathlessness.Inthesetting
ofchronicsevereMVdisease,symptomsmaybeverygradualandverysubtle,
suchasbeingunabletocompleteafullgameoffootball—thusshortnessof
breathduringpeakphysicalactivity.Thismayprogresstoshortnessofbreathat
rest,followedintimebyclinicaldecompensationanddeath.Morerapid
progressionofsymptomscanalsooccurinthesettingofacute-on-chronicMV
disease.
TheclinicalsignsofMRincludeapansystolicmurmurheardbestattheapex
withradiationtotheaxilla,asthedirectionofregurgitantjetisusually
posterolateral.Lesscommonlythemurmurradiatesmediallyiftheregurgitant
jetisdirectedthatway.PatientswithmoderateormoresevereMRwillhave
lateraldisplacementoftheapexbeat,andtheremaybeanassociateddiastolic
murmurrelatedtoincreasedtransmitralflow.
IfMRissevere,ECGandchestx-radiograph(CXR)willdemonstrateleft
ventricular(LV)dilatation/hypertrophyaswellaspulmonarycongestion.

MitralStenosis
InthesettingofMVstenosis,progressiveobstructiontoLVinflowdevelops,
leadingtoadiastolicgradientbetweentheleftatriumandventricle.This
pressuregradientisincreasedinsettingsofincreasedflowandfasterheartrates,
forexampleduringexercise,pregnancy,orinthepresenceofatrialfibrillation
withrapidventricularrates.Patientsusuallydonotdevelopsymptomsuntilthe
MVorificedecreasestolessthan2cm2.Theinitialsymptomisexertional

dyspneawithsymptomsoforthopneaandparoxysmaldyspneaastheMVorifice
decreasestolessthan1.0to1.5cm2.31,32Symptomsofcough,hemoptysis,chest


pain,palpitations,hoarsevoiceduetocompressionoftheleftrecurrentlaryngeal
nerveandleftatrialdilatationaresignsofveryadvanceddisease.33
ThecharacteristicclinicalfindingofmildtomoderateMSisalow-pitched,
diastolicrumbleorheartmurmurheardbestattheapexwiththepatientinaleft
lateralposition.Themurmurisaccentuatedbyincreasingheartratewithmild
exercise.Asdiseaseprogressesinseverity,thepulsesbecomesmallinvolume
andaparasternalheaveandloudP2developduetopulmonaryhypertension.
Unlessthepatientisinatrialfibrillation(AF),thedurationofthemurmur
increasesandapresystolicaccentuationdevelops.Lesscommonly,patientsmay
presentwithorhavesignsofsystemicembolismfromtheleftatrium,although
thisislikelyrelatedmoretothedevelopmentofAFratherthantheseverityof
theMSinitself.34
ECGisusefultoconfirmsinusrhythmorAF.Leftatrialenlargementandright
ventricularhypertrophyisamarkerofseveredisease.CXRmayshowleftatrial
enlargementandupperlobediversionofbloodflow.CalcificationoftheMV
apparatusmaybevisible,aswellaspulmonarycongestionifinheartfailure.

AorticRegurgitation
Patientswithchronicstablemoderateorsevereregurgitationoftenremain
asymptomaticforyears.Eventuallydyspneaonexertion,orthopnea,andeven
paroxysmalnocturnaldyspneaandedemadevelop.Anginacanoccur,evenifthe
patienthasnormalcoronaryarteries,astheresultofreducedcoronaryperfusion
duetolowdiastolicbloodpressure.
TheclinicalsignsofmildARarenormalpulsesandanearlydiastolic,
blowingdecrescendodiastolicmurmurbestheardatthelowerleftsternaledgeat
theendofexpirationwiththepatientsittinguprightandleaningforward.In

general,moreseverediseaseisassociatedwithashortermurmur.Awidened
pulsepressureindicatesmoderatetosevereAR.Collapsingpulsesindicate
severeAR.IntorrentialAR,themurmurisheardwiththepatientlyingflatand
isassociatedwithwhatisdescribedasa“water-hammerpulse.”TheKorotkoff
soundsareheardalmostdowntothepressureofzero.Theapicalimpulseis
hyperdynamicanddisplacedduetoLVenlargement.Thepresenceofasystolic
flowmurmuracrosstheAVreflectsincreasedstrokevolume.
IfARissevere,theECGwillshowincreasedLVvoltagesandtheCXRwill
demonstrateleftventricleenlargement.


AorticStenosis
Mildtomoderateaorticstenosisisoftenasymptomaticandisassociatedwithan
ejectionsystolicmurmurattherightuppersternaledge.
Withsevereaorticstenosis,aclassictriadofsymptomsmaydevelop:dyspnea
onexertion,angina,andsyncope.Onauscultation,aloud,low-pitched
midsystolicejectionmurmurintheaorticareawillbenoted,radiatingtothe
neckandoftenassociatedwithathrillovertheaorticareaandatthesuprasternal
notch.
Inthesettingofsevereaorticstenosis,anECGwillshowLVhypertrophy.The
CXRoftenremainsnormalinisolatedaorticstenosis.

TricuspidRegurgitation
Symptomsoftricuspidregurgitationareoftenmorerelatedtotheseverityof
coexistingMVdisease.Specificfeaturesduetotricuspidregurgitationinclude
abdominaldiscomfortduetohepatomegaly,ascites,weightloss,andjaundice.If
tricuspidregurgitationissevereonclinicalassessment,jugularvenouspressure
willbeelevated.Apansystolic,low-pitchedcardiacmurmurwillbeheard,
loudestattheleftlowersternaledge,thatincreasesinintensitywithinspiration.
Iftricuspidregurgitationissecondarytopulmonaryhypertension,themurmur

tendstobehigher-pitchedwithaloudsecondheartsound.33