From the Guidelines
Auscultatory findings of valvular stenosis include specific murmurs and associated sounds that help identify each condition, with Aortic Stenosis (AS) presenting with a harsh, crescendo-decrescendo systolic ejection murmur, Mitral Stenosis (MS) with a low-pitched, rumbling mid-diastolic murmur, Tricuspid Stenosis (TS) with a mid-diastolic rumbling murmur, and Pulmonary Stenosis (PS) with a systolic ejection murmur. The key characteristics of these murmurs are as follows:
- Aortic Stenosis (AS): harsh, crescendo-decrescendo systolic ejection murmur best heard at the right upper sternal border with radiation to the carotids, increasing with squatting and decreasing with standing or Valsalva, and may demonstrate a soft or absent S2 and an S4 gallop 1.
- Mitral Stenosis (MS): low-pitched, rumbling mid-diastolic murmur best heard at the apex with the bell of the stethoscope while the patient is in the left lateral position, typically with an opening snap after S2 and increased murmur intensity with exercise 1.
- Tricuspid Stenosis (TS): mid-diastolic rumbling murmur similar to MS but best heard at the left lower sternal border and increases with inspiration (Carvallo's sign) 1.
- Pulmonary Stenosis (PS): systolic ejection murmur heard best at the left upper sternal border with radiation to the back and left shoulder, increasing with inspiration and may be accompanied by a systolic ejection click that decreases with inspiration 1. These auscultatory findings reflect the turbulent blood flow across narrowed valves, with timing and quality determined by the specific valve affected and the pressure gradient across it. Some important associated findings include:
- Fixed splitting of the second heart sound during inspiration and expiration suggesting an atrial septal defect
- A soft or absent A2 or reversed splitting of S2 denoting severe AS
- An early aortic systolic ejection sound suggesting a bicuspid aortic valve
- LV dilatation on precordial palpation and bibasilar pulmonary rales favoring severe, chronic MR
- A slow-rising, diminished arterial pulse suggesting severe AS. It is essential to consider these findings in the context of the patient's overall clinical presentation to accurately diagnose and manage valvular stenosis.
From the Research
Auscultatory Findings of Valvular Diseases
The auscultatory findings of Aortic Stenosis (AS), Mitral Stenosis (MS), Tricuspid Stenosis (TS), and Pulmonary Stenosis (PS) are as follows:
- Aortic Stenosis (AS): characterized by a harsh, crescendo-decrescendo systolic murmur best heard at the right second intercostal space 2, 3, 4, 5, 6
- Mitral Stenosis (MS): typically presents with a low-pitched, rumbling diastolic murmur best heard at the apex 2, 3, 4, 5
- Tricuspid Stenosis (TS): usually presents with a diastolic murmur best heard at the left lower sternal border, which increases with inspiration 3, 4, 6
- Pulmonary Stenosis (PS): characterized by a harsh, crescendo-decrescendo systolic murmur best heard at the left second intercostal space, however, there is no direct evidence provided in the given studies to support this claim
Clinical Implications
The presence of concomitant valvular diseases can affect the clinical implications and treatment strategies for patients with AS, MS, TS, and PS. For example:
- Patients with severe AS and concomitant MS may benefit from transcatheter aortic valve replacement (TAVR) as a safe and attractive option with less complications compared to surgical aortic valve replacement (SAVR) 2
- The presence of significant tricuspid regurgitation (TR) in patients with AS is associated with dismal outcomes, regardless of the treatment strategy 3, 6
- The hemodynamic interactions between AS and other valvular diseases can result in diagnostic pitfalls at echocardiography, and other imaging modalities may be helpful 4