What are the expected auscultation findings in a patient with eccentric left ventricular hypertrophy (LVH), dilated left atrium, right atrium, and right ventricle, mild to moderate mitral valve stenosis with severe mitral regurgitation, aortic valve sclerosis with aortic regurgitation, severe tricuspid regurgitation, and mild pulmonic regurgitation?

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Auscultation Findings in Complex Valvular Heart Disease with Eccentric LVH

The patient with eccentric left ventricular hypertrophy, dilated chambers, and multiple valvular lesions will demonstrate a holosystolic murmur at the apex radiating to the axilla (mitral regurgitation), a mid-diastolic rumble at the apex (mitral stenosis), an early diastolic decrescendo murmur at the left sternal border (aortic regurgitation), and a holosystolic murmur at the lower left sternal border that increases with inspiration (tricuspid regurgitation).

Mitral Valve Findings

  • A holosystolic murmur will be heard best at the apex (mitral area) with radiation to the left axilla due to severe mitral regurgitation 1
  • A mid-diastolic rumble with presystolic accentuation will be present at the apex due to mild-to-moderate mitral stenosis 1
  • The first heart sound (S1) may be diminished due to decreased mobility of the mitral valve leaflets 1
  • The presence of dilated left atrium will contribute to a widely split S2 1

Aortic Valve Findings

  • An early diastolic decrescendo murmur will be heard along the left sternal border due to aortic regurgitation (grade 3+) 1
  • Possible soft systolic ejection murmur at the right upper sternal border due to aortic valve sclerosis 1
  • The second heart sound (S2) may be diminished due to aortic valve sclerosis 1
  • The combination of aortic regurgitation and eccentric LVH may produce a hyperdynamic apical impulse 1, 2

Tricuspid Valve Findings

  • A holosystolic murmur will be heard at the lower left sternal border or xiphoid area that increases with inspiration (Carvallo's sign) due to severe tricuspid regurgitation 1
  • The murmur may be accompanied by a prominent v wave in the jugular venous pulse 1
  • Right atrial enlargement may contribute to a third heart sound (S3) on the right side 1

Pulmonic Valve Findings

  • A soft early diastolic decrescendo murmur may be heard at the left upper sternal border due to mild pulmonic regurgitation, though this may be difficult to distinguish from the aortic regurgitation murmur 1
  • The pulmonic component of S2 may be diminished 1

Additional Auscultatory Findings

  • A third heart sound (S3) will likely be present due to volume overload from multiple regurgitant lesions and eccentric LVH 1, 2
  • A fourth heart sound (S4) may be present due to decreased ventricular compliance 1
  • The presence of eccentric LVH with adequate systolic function will produce a hyperdynamic precordial impulse 2
  • Biventricular enlargement may produce a sustained apical impulse displaced laterally and inferiorly 1

Clinical Pearls and Pitfalls

  • The multiple valvular lesions may create complex auscultatory findings that can mask each other; careful auscultation in different positions is essential 1
  • Eccentric LVH is characterized by chamber dilation with normal wall thickness-to-chamber radius ratio, unlike concentric LVH which has increased wall thickness 2
  • The presence of multiple regurgitant lesions may lead to overestimation or underestimation of individual valve lesion severity by physical examination alone 1
  • Auscultation during different respiratory phases is crucial to differentiate right-sided from left-sided murmurs (right-sided murmurs increase with inspiration) 1
  • Dynamic auscultation with maneuvers (Valsalva, standing, squatting) may help distinguish between different murmurs 1
  • The combination of eccentric LVH with multiple valvular lesions often produces a "busy" precordium with multiple murmurs that may overlap 3

Special Considerations

  • The eccentric LVH pattern in this patient is likely due to chronic volume overload from multiple regurgitant lesions 2
  • The dilated chambers (left atrium, right atrium, right ventricle) will influence the auscultatory findings by affecting heart sounds and murmur intensity 1
  • Careful attention to the timing, location, radiation, and response to respiration of each murmur is essential for accurate diagnosis 3
  • The presence of adequate systolic function suggests compensated heart disease despite multiple valve lesions 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Cardiac auscultation: rediscovering the lost art.

Current problems in cardiology, 2008

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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