A 68-year-old woman is referred to you for evaluation of a murmur.
She tells you she was diagnosed with a murmur and an abnormal heart valve as a young woman.
She takes antibiotics before visiting the dentist
but says she feels well she walks two miles every day without symptoms.
Her physical exam show something interesting.
First of all, her systolic pressure is a little bit elevate at 145 and her diastolic pressure is very low at 48
so there are several things that could go this -
very stiff arteries can give you this wide pulse pressure as could a valvular lesion aortic insufficiency
or also called aortic regurgitation.
The pulse is regular at a reasonable rate, fingertip oxygen saturation normal.
JVP is normal, jugular venous pulse that is quite normal, carotid pulse is very brisk.
The brisk carotid pulse and the wide pulse pressure are suggesting to be this patient may have aortic insufficiency.
Her lungs are clear so there’s not heart failure and heart sounds,
she has a grade 2 systolic ejection murmur and a grade 2 diastolic murmur heard
at the upper right sternal border and no S3 again consistent with an aortic regurgitation.
The systolic murmur doesn’t mean she has an aortic stenosis it’s just because of the increased flow
that goes across an abnormal aortic valve during systole so let’s imitate that.
So normal heart, lub-dub, lub-dub, lub-dub. Here’s her: lub-shshdub-whoo, lub-shshdub-whoo, lub-shshdub-whoo.
So you heard there's two murmurs the systolic ejection murmur
because of turbulence from the large flow going across the aortic valve
and then the diastolic blowing murmur of aortic insufficiency.
She has no peripheral edema so there’s nothing in the exam or the history that suggest heart failure.
So what's the critical factors here?
She has a history of heart disease so you’re gonna be looking for a valvular heart disease
and of course her physical exam shows you a wide pulse pressure
as well as signs of aortic valve disease. We do a chest x-ray and then we’ll do a Doppler echo.
Here’s the chest x-ray - her left ventricle is enlarged, you can see again the apex is pushing out
towards the chest wall but the lungs are clear
and in the aortic regurgitation also one has an enlarged aortic route
and you can see that on this view of the chest x-ray, the dilated ascending aorta.
And here’s the Doppler, you can see in the rainbow color area
a large amount of aortic regurgitation flowing across the aortic valve.
Large regurgitant jet flowing across an abnormal aortic valve.
Other options, her blood test are all normal, kidney functions normal which is good,
so the conclusion of the echo is that she has moderately severe aortic insufficiency,
she has a bicuspid aortic valve.
One percent of the population is born with a two cusp aortic valve rather than a three cusp
and the bicuspid aortic valve wears out early,
sometimes associate also with the ascending aortic aneurysm or dilation of the ascending aorta.
The left ventricle is enlarged but has normal ejection fraction so normal functioning
and she has an enlarged aortic route which is quite common with a bicuspid aortic valve.
The bicuspid valve can go on to either stenosis or regurgitation with time,
in this case it went on to aortic regurgitation and the left ventricle dilates
in order to pump the larger end diastolic volume into the aorta
because of the blood that flows back into the left ventricle during diastole with the aortic regurge.
If the aortic regurgent volume is very large left ventricular failure can eventually develop
and that requires replacement of the aortic valve.