Question 16

College Answer

a) Any five of:        

• Collapsing pulse/wide pulse pressure
• Length of decrescendo diastolic murmur
• LV third heart sound
• Soft A2
• [Austin Flint (mid-diastolic) murmur]
• Left ventricular failure
• Displaced apex beat

b)             

• Symptoms- exertional angina, dyspnoea on exertion, syncope.
• Worsening LV failure (falling ejection fraction)
• Progressive LV dilatation on serial echocardiography (LV end systolic dimensions >5.5 cm)

c) Any five of:                                                                                         

• Aortic Stenosis-diamond-shaped (crescendo-decrescendo), heard best at the right upper sternal border, radiates to the right supraclavicular area, and to the carotids
• Mitral regurgitation-blowing, harsh, holosystolic murmur heard best at the apex, usually radiates to the axilla or back.
• Pulmonary stenosis- diamond-shaped systolic, heard best at the left upper sternal border, may radiate to back
• Tricuspid regurgitation-harsh, holosystolic murmur heard best at the left lower sternal border.
• Subaortic stenosis/HOCM-harsh, diamond-shaped, mid-systolic murmur heard best at the left sternal border
• Mitral Valve Prolapse-mid-systolic click followed by a brief crescendo-decrescendo murmur, usually best at the apex
• Ventricular Septal Defect- holosystolic murmur, best heard over lower left sternal border, with radiation to the right lower sternal border 
• Atrial Septal Defect- mid-systolic flow murmur best heard over the “pulmonic area” of the chest, and may radiate into the back followed by fixed split S2.
• Patent Ductus Arteriosus- To & fro machinery murmur (systolic and diastolic)

Discussion

a)

One might expect that deatures suggestive of severity in chronic AR would be mainly features related to the effect of AR on cardiac function, not just generic features of AR

• LV dilatation (displaced apex, diffuse hyperdynamic impulse)
• Congestive cardiac failure (low blood pressure, peripheral oedema)
• Poor exercise tolerance
• Signs of widened pulse pressure (see below)
• An S3, suggestive of poor LV function

Generic features of AR are as follows:

• Signs of widened pulse pressure:
  These were mentioned in Question 14.2 from the first paper of 2013
  • Corrigans sign: a "jerky" carotid pulse: full expansion, followed by complete collapse. You're palpating the pressure of the left ventricle, essentially. It's named after a 19th century Irishman. It indicates a severe aortic incompetence.
  • de Musset's sign which the college answer has spelled incorrectly is  a visible nodding of the head in time with arterial pulsation in patients with severe aortic insufficiency. It is named after an aortically insufficient French poet.
  • Quincke's sign, otherwise known as Quincke's pulse, is a nail sign: it is seen when the nailbed is blanched. The pale nail bed flashed red and white as capillary refill is restored. It can also be seen in the absence of any aortic problems, in patients who have sclerodactily.
  • Duroziez's sign is elicited by listening over the femoral artery with the bell of the stethoscope. It is supposed to be a double murmur. According to some recent evidence, it has almost 100% specificity. There is supposed to be both a systolic and a diastolic bruit, as blood rushes into - and then rapidly out of - the femoral artery.
• These are mentioned in UpToDate:
  • Traube's sign – A pistol shot pulse (systolic and diastolic sounds) heard over the femoral arteries.
  • Mueller's sign – Systolic pulsations of the uvula.
  • Becker's sign – Visible pulsations of the retinal arteries and pupils.
  • Hill's sign – Popliteal cuff systolic pressure exceeding brachial pressure by more than 20 mmHg with patient in the recumbent position.
  • Mayne's sign – More than a 15 mmHg decrease in diastolic blood pressure with arm elevation from the value obtained with the arm in the standard position.
  • Rosenbach's sign – Systolic pulsations of the liver.
  • Gerhard's sign – Systolic pulsations of the spleen. 
• Chacteristic auscultatory findings:
  • Soft S1
  • Soft A2
  • An S3 if LV function is severely depressed
  • A systolic ejection sound due to abrupt aortic distension

b)

Indications for valve replacement, as given in the 2014 AHA/ACC guidelines, are as follows:

• Symptomatic patients:
  • When the AR is Stage D, i.e with a dilated LV, Doppler jet width ≥65% of LVOT and holodiastolic flow reversal in the proximal abdominal aorta
• Asymptomatic patients:
  • LVEF <50%
  • Normal LVEF, but with significant LV dilatation (end-systolic diameter > 50mm or end-diastolic diameter >65mm)
  • None of the above, but about to undergo cardiac surgery anyway (for some other reason)

c)

Causes of systolic murmurs and their characteristic auscultatory findings:

Nicholas Joseph Talley, Simon O'Connor; Clinical Examination: A Systematic Guide to Physical Diagnosis (7th ed)

SEGAL, JACK P., W. PROCTOR HARVEY, and MICHAEL A. CORRADO. "The Austin Flint murmur: its differentiation from the murmur of rheumatic mitral stenosis." Circulation 18.5 (1958): 1025-1033.

Leatham, Aubrey. "Splitting of the first and second heart sounds." The Lancet 264.6839 (1954): 607-614.

Sabbah, HANI N., and PAUL D. Stein. "Investigation of the theory and mechanism of the origin of the second heart sound." Circulation research 39.6 (1976): 874-882.

Saberi, Asif, and Saeed A. Syed. "Corrigan’s sign." Hospital Physician (1999): 29.

DAVIES, M., and A. Hollman. "de Musset sign." Heart 82.3 (1999): 262.

Norton, S. A. "Keratoderma with pseudo-Quincke's pulse." Cutis 62.3 (1998): 135-136.

Sapira, J. D. "Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations." Southern medical journal 74.4 (1981): 459-467.

Luisada, Aldo A. "On the pathogenesis of the signs of Traube and Duroziez in aortic insufficiency. A graphic study." American Heart Journal 26.6 (1943): 721-736.

BLUMGART, HERRMAN L., and A. CARLTON ERNSTENE. "Two mechanisms in the production of Duroziez's sign: their diagnostic significance and a clinical test for differentiating between them." Journal of the American Medical Association 100.3 (1933): 173-177.

Nishimura, Rick A., et al. "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 63.22 (2014): e57-e185.