The crescendo-decrescendo systolic murmur is best heard at the cardiac base
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Reference works and clinical literature report that the crescendo-decrescendo systolic murmur (associated with aortic stenosis or ejection murmurs) is typically heard loudest at the cardiac base, specifically the upper right or left sternal border in the second intercostal space.
easily heard systolic, crescendo-decrescendo (i.e., 'ejection') murmur is heard loudest at the upper right sternal border, at the 2nd right intercostal
Aortic stenosis (AS or AoS) is the narrowing of the outlet of the main pumping chamber of the heart, the left ventricle (LV) (where the aorta begins). If the narrowing is severe (very tight) the extra work required from the left ventricle to pump the blood against the increased resistance of a small orifice may cause (initially adaptive) thickening of the heart muscle, followed by severe weakness
sustained, heaving apex beat, which is not displaced unless systolic dysfunction of the left ventricle has developed
A precordial thrill
narrowed pulse pressure
Echocardiogram (heart ultrasound) is the best non-invasive way to evaluate the aortic valve anatomy and function.
Any angina is generally treated with beta-blockers and/or calcium blockers. Nitrates are contraindicated due to their potential to cause profound hypotension in aortic stenosis.
Any hypertension is treated aggressively, but caution must be taken in administering beta-blockers. The optimal blood pressure in patients with asymptomatic aortic stenosis and no manifest atherosclerotic disease or diabetes mellitus was found to be a systolic blood pressure of 130-139 mmHg and a diastolic blood pressure of 70-90 mmHg.
Any heart failure is generally treated with digoxin and diuretics, and, if not contraindicated, cautious administration of ACE inhibitors.
In adults, symptomatic severe aortic stenosis usually requires aortic valve replacement (AVR). While Surgical AVR has remained the most effective treatment for this disease process and is currently recommended for patients after the onset of symptoms, as of 2016 aortic valve replacement approaches included open-heart surgery,…
77-YEAR-OLD, 175-cm, 71-kg man was admitted to the authors’ institution for evaluation of progressive dyspnea on exertion and reduced exercise tolerance of 2 years duration. His symptoms occasionally were accompanied by chest pressure without radiation and were relieved consistently with rest. The patient also described intermittent paroxysmal nocturnal dyspnea and recent lower-extremity swelling, but he denied orthopnea, diaphoresis, syncope, and palpitations. The patient had undergone 2-vessel coronary artery bypass graft surgery and an aortic valve replacement with a Carpentier-Edwards bioprosthetic valve (Edwards Life Sciences, Irvine, CA) for aortic insufficiency 24 years before the current admission. The patient’s past medical history also was notable for chronic atrial fibrillation (for which he received digoxin and warfarin), wellcontrolled essential hypertension (treated with carvedilol, lisinopril, and furosemide), and hyperlipidemia (treated with simvastatin). The physical examination revealed a harsh grade III of VI crescendo-decrescendo systolic murmur best heard at the 4th left intercostal space that radiated to the left axilla. A second, lower-pitched holosystolic murmur (grade II of VI) was noted at the 2nd right intercostal space. A grade II of VI early diastolic murmur also was heard at the left ventricular apex. Auscultation of the lungs indicated bilateral basilar rales. There was jugular venous distention present, and lower-extremity pitting edema was obs
<h4>Background</h4>Lysosomal storage diseases (LSDs) are rare, progressive, multi-organ disorders caused by inherited enzyme deficiencies. Gaucher's disease (GD) is the most prevalent form of LSDs.<h4>Case summary</h4>A 19-year-old Caucasian male presented with exertional dyspnoea. Physical examination revealed a Grade III/VI systolic diamond murmur at the heart base and a Grade IV/VI systolic murmur at the apex. Electrocardiogram showed signs of left ventricular hypertrophy (LVH). Trans-thoracic echocardiography (TTE) and trans-oesophageal echocardiography (TEE) demonstrated moderate LVH, severe aortic valve stenosis, severe supra-valvular aortic stenosis, and moderate mitral stenosis with severe degenerative mitral valve regurgitation. Bone marrow biopsy and aspiration confirmed the presence of characteristic Gaucher's cells. The patient underwent the Bentall procedure and mitral valve replacement and was discharged in good condition.<h4>Discussion</h4>Gaucher's disease exhibits three clinical phenotypes, and cardiovascular involvement is commonly seen in GD Type III. Valvular calcification and ascending aorta involvement are frequent cardiovascular manifestations. Although severe valvular heart involvement is rare in GD, cardiac valve surgery has shown favourable outcomes in previous studies and our case.
A 38-year-old man presented with two episodes of transient loss of consciousness accompanied by intermittent palpitations and some episodes of dizziness over the last several months. Loss of consciousness was associated with the loss of postural tone followed once by a fall with a head injury. He had no prior cardiac history but was diagnosed with lymphoblastic lymphoma at the age of 7 years. He had been treated with irradiation to the left supraclavicular region and subsequent chemotherapy. Physical examination revealed 3/6 crescendo-decrescendo systolic murmur best heard at the second intercostal space in the right upper sternal border and radiating to the carotid arteries. There was also other 2/6 holosystolic murmur loudest over the apex with radiation to the left axilla. An ECG demonstrated normal sinus rhythm …
aortic valve replacement. The patient described a 4-month history of progressive dyspnea on exertion that markedly reduced his exercise tolerance. He reported worsening orthopnea; a persistent, productive cough; paroxysmal nocturnal dyspnea; and swelling in his lower extremities, but he denied chest pain, palpitations, and syncope. The past medical history was notable for essential hypertension (treated with atenolol, losartan, and hydrochlorothiazide), hyperlipidemia (for which the patient received simvastatin), and type II diabetes mellitus (treated with insulin, glipizide, and metformin). The physical examination revealed a grade III of VI crescendo-decrescendo systolic murmur best heard in the left 2nd intercostal space that radiated to the carotid arteries bilaterally. Two-dimensional transthoracic echocardiography showed the presence of a heavily calcified trileaflet aortic valve with restricted leaflet motion consistent with severe aortic stenosis. Concentric left ventricular hypertrophy was present, but no regional wall motion abnormalities were observed. The mean and peak gradients across the aortic valve were determined to be 37.5 and 58.4 mmHg, respectively, by using continuous-wave Doppler echocardiography. Color Doppler blood flow mapping also indicated the presence of mild aortic insufficiency. The aortic valve area and left ventricular ejection fraction were estimated to be 0.93 cm 2 and 53%, respectively. A cardiac catheterization confirmed the echocardiograph
Auscultation may reveal a systolic murmur of a harsh crescendo-decrescendo type, heard in 2nd right intercostal space and radiating to the carotid arteries. Patients
Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left side of heart and the pulmonic and tricuspid valves on the right side of heart). These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic proce
Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left side of heart and the pulmonic and tricuspid valves on the right side of heart). These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.
Anatomically, the valves are part of the dense connective tissue of the heart known as the cardiac skeleton and are responsible for the regulation of blood flow through the heart and great vessels. Valve failure or dysfunction can result in diminished heart functionality, though the particular consequences are dependent on the type and severity of valvular disease. Treatment of damaged valves may involve medication alone, but often involves surgical valve repair or valve replacement.
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