Mitral Stenosis (MS)

Features

•    Diastolic murmur:

o    Mid-diastolic, low-pitched "rumbling"

o    Best heard at apex in left lateral position

•    Opening snap:

o    Occurs shortly after S2; earlier snap → more severe stenosis

Causes

•    Rheumatic heart disease (most common worldwide)

Other signs

•    Malar flush (due to pulmonary hypertension)

•    Tapping apex beat

•    Signs of right heart failure in advanced disease

Mitral Regurgitation (MR)

Features

•    Pansystolic murmur

o    Heard best at apex

o    Radiates to axilla

Causes

•    Mitral valve prolapse

•    Ischaemic (papillary muscle dysfunction)

•    Rheumatic disease

•    Infective endocarditis

Other signs

•    Soft S1

•    Displaced hyperdynamic apex beat

•    S3 if volume overload

Aortic Stenosis (AS)

Features

•    Ejection systolic murmur

o    Crescendo-decrescendo

o    Loudest at right second ICS, radiates to carotids

Associated signs

•    Slow-rising pulse (anacrotic)

•    Narrow pulse pressure

•    Heaving apex beat

Causes

•    Calcific degeneration (elderly)

•    Bicuspid aortic valve (younger patients)

•    Rheumatic (less common in UK)

Aortic Regurgitation (AR)

Features

•    Early diastolic murmur

o    High-pitched, blowing

o    Best heard at left sternal edge with patient sitting forward in expiration

Associated signs (wide pulse pressure)

•    Collapsing (water hammer) pulse

•    Corrigan’s sign: carotid pulsation

•    Quincke’s sign: capillary pulsation in nails

•    De Musset’s sign: head bobbing

•    Traube’s sign: "pistol-shot" femoral sounds

Causes

•    Aortic root dilation (Marfan, syphilis)

•    Rheumatic disease

•    Endocarditis

Tricuspid Regurgitation (TR)

Features

•    Pansystolic murmur

o    Best heard at lower left sternal edge

o    Intensified on inspiration (Carvallo’s sign)

Causes

•    Pulmonary hypertension

•    RV dilatation

•    Rheumatic disease

•    Endocarditis (especially in IV drug users)

Infective Endocarditis (IE)

Features

•    Fever + new murmur = classic clue

•    Embolic phenomena (Janeway lesions, splinter haemorrhages)

•    Immunological signs (Osler’s nodes, Roth spots, glomerulonephritis)

Common organisms

•    Strep viridans: most common in previously abnormal/native valves

•    Staph aureus: most common overall, esp. IV drug users, prosthetic valves

•    Enterococci: elderly, urinary tract manipulation

Diagnosis

•    Duke criteria

o    Major: positive blood cultures (typical organisms), evidence of endocardial involvement (echo)

o    Minor: predisposition, fever, vascular/immunological phenomena, other microbiology

Management

•    IV antibiotics (based on sensitivities; often 4–6 weeks)

•    Surgery if:

o    Heart failure from valve dysfunction

o    Uncontrolled infection

o    Recurrent emboli

Prosthetic Valves

Types

•    Mechanical:

o    Durable

o    Require lifelong anticoagulation (target INR ~2.5–3.5 depending on valve position/type)

•    Bioprosthetic (tissue) valves:

o    Less durable (10–15 years)

o    Usually no long-term anticoagulation needed (unless other indication)

Complications

•    Thromboembolism

•    Structural degeneration (bioprosthetic)

•    Prosthetic valve endocarditis

Extra Revision Pearls

•    MS severity clue → shorter S2–OS interval = more severe

•    AS triad → syncope, angina, dyspnoea

•    MR clue → radiates to axilla; TR → louder on inspiration (Carvallo’s)

•    IVDU → right-sided IE (tricuspid), Staph aureus most common

•    Osler’s nodes (tender) = immunological; Janeway lesions (non-tender) = embolic

•    Mechanical valves in mitral position = higher thrombosis risk than aortic → higher INR target