TABLE 10-1 - Differential diagnosis of valvular heart disease

	Mitral Stenosis	Mitral Regurgitation	Aortic Stenosis	Aortic Regurgitation	Tricuspid Stenosis	Regurgitation
Inspection	Malar flush, precordial bulge, and diffuse pulsation in young patients.	bulge, and diffuse pulsation in young patients. Usually prominent and hyperdynamic apical impulse to left of MCL.	Sustained PMI, prominent atrial filling wave.	Hyperdynamic PMI to left of MCL and down. Visible carotid pulsations.	Giant a wave in jugular pulse with sinus rhythm. Often olive-colored skin (mixed jaundice and local cyanosis).	Large v wave in jugular pulse.
Palpation	"Tapping" sensation over area of expected PMI. Mid-diastolic or presystolic thrill at apex. Small pulse. Right ventricular pulsation left third to fifth ICS parasternally when pulmonary hypertension is present.	Forceful, brisk PMI; systolic thrill over PMI. Pulse normal, small, or slightly collapsing.	Powerful, heaving PMI to left and slightly below MCL. Systolic thrill over aortic area, sternal notch, or carotids. Small and slowly rising carotid pulse	Apical impulse forceful and displaced significantly to left and down. Prominent carotid pulses. Rapidly rising and collapsing pulses.	Middiastolic thrill between lower left sternal border and PMI. Presystolic pulsation of liver (sinus rhythm only).	Right ventricular pulsation. Occasionally systolic thrill at lower left sternal edge. Systolic pulsation of liver.
Heart sounds, rhythm, and blood pressure	Loud snapping M₁. Opening snap following S₂ along left sternal border or at apex. Atrial fibrillation common. Blood pressurenormal.	M₁ normal or buried in murmur. Prominent third heart sound. Atrial fibrillation common. Blood pressure normal. Midsystolic clicks may be present.	A₂ normal, soft, or absent. Paradoxic splitting of S₂ if A₂ is audible. Prominent S₄. Blood pressure normal, or systolic pressure normal with high diastolic.	S₁ normal or reduced, A₂ loud. Wide pulse pressure with diastolic pressure > 60 mm Hg.	S₁ often loud.	Atrial fibrillation is usually present.
Murmurs Location and transmission	Localized at or near apex. Rarely, short diastolic (Graham Steell) murmur along lower left sternal border in severe pulmonary hypertension.	Loudest over PMI; transmitted to left axilla, left infrascapular area. With posterior papillary muscle dysfunction, may transmit to base.	Right second ICS parasternally or at apex, heard in carotids and occasionally in upper interscapular area.	Diastolic: louder along left sternal border in third to fourth interspace. Heard over aortic area and apex. May be associated with low-pitched middiastolic murmur at apex (Austin Flint) in nonrheumatic disease.	Third to fifth ICS along left sternal border out to apex	As for tricuspid stenosis.
Timing	Onset at opening snap ("middiastolic") with presystolic accentuation if in sinus rhythm. Graham Steell begins with P₂ (early diastole).	Pansystolic: begins with M₁ and ends at or after A₂. May be late systolic in papillary muscle dysfunction.	Midsystolic: begins after M₁, ends before A₂, reaches maximum intensity in mid systole.	Begins immediately after aortic second sound and ends before first sound.	As for mitral stenosis	As for mitral regurgitation
Character	Low-pitched, rumbling; presystolic murmur merges with loud M1 and ends at or after A₂. May be late systolic in papillary muscle dysfunction.	Blowing, high-pitched; occasionally harsh or musical.	Harsh, rough.	Blowing, often faint	As for mitral regurgitation	Blowing, coarse, or musical
Optimum₁ auscultatory conditions	After exercise, left lateral recumbency. Bell chest piece lightly applied	After exercise; diaphragm chest piece. In prolapse, findings most prominent while standing	Patient resting, leaning forward, breath held in full expiration.	Patient leaning forward, breath held in expiration.	Murmur usually louder and at peak during inspiration. Patient recumbent	Murmur usually becomes louder during inspiration
X-ray	Straight left heart border. Large left atrium sharply indenting esophagus. Elevation of left main stem bronchus. Large right ventricle and pulmonary artery if pulmonary hypertension is present. Calcification occasionally seen in mitral valve.	Enlarged left ventricle and left atrium.	Concentric left ventricular hypertrophy. Prominent ascending aorta, small knob. Calcified valve common	Moderate to severe left ventricular enlargement. Prominent aortic knob	Enlarged right atrium only	Enlarged right atrium and ventricle
Electrocardiography	Broad P waves in standard leads; broad negative phase of diphasic P in V₁. If pulmonary hypertension is present, tall peaked P waves, right axis deviation, or right ventricular hypertrophy appears	Left axis deviation or frank left ventricular hypertrophy. P waves broad, tall, or notched in standard leads. Broad negative phase of diphasic P in V₁	Left ventricular hypertrophy	Left ventricular hypertrophy	Tall, peaked P waves. Normal axis	Right axis usual
Echocardiography M mode	Thickened, immobile mitral valve with anterior and posterior leaflets moving together. Slow early diastolic filling slope, left atrial enlargement, normal to small left ventricle	Thickened mitral valve in rheumatic disease; mitral valve prolapse; flail leaflet or vegetations may be seen. Enlarged left ventricle with above-normal, normal, or decreased function	Dense persistent echoes from the aortic valve with poor leaflet excursion, left ventricular hypertrophy with preserved contractile function	Diastolic vibrations of the anterior leaflet of the mitral valve and septum, early closure of the mitral valve when severe, dilated left ventricle with normal or decreased contractility	Tricuspid valve thickening, decreased early diastolic filling slope of the tricuspid valve. Mitral valve also usually abnormal	Enlarged right ventricle prolapsing valve, mitral valve often abnormal
Two-dimensional	Maximum diastolic orifice size reduced, subvalvular apparatus foreshortened, variable thickening of other valves	Same as M mode but more reliable	Above plus poststenotic dilation of the aorta, restricted opening of the aortic leaflets, bicuspid aortic valve in about 30%	Above plus may show vegetations in endocarditis, bicuspid valve, root dilation	Above plus enlargement of the right atrium	Same as above
Doppler	Prolonged pressure halftime across mitral valve; indirect evidence of pulmonary hypertension	Regurgitant flow mapped into left atrium; indirect evidence of pulmonary hypertension	Increased transvalvular flow velocity, yielding calculated gradient. Valve area estimate using continuity equation	Demonstrates regurgitation and qualitatively estimates severity	Prolonged pressure halftime across tricuspid valve	Regurgitant flow mappedinto right atrium and venae cavae; right ventricular systolic pressure estimated

A₂= Aortic second sound
MCL = Midclavicular line
S₂ = Second heart sound
ICS = Intercostal space
P₂= Pulmonary second sound
S₄ = Fourth heart sound
M₁= Mitral first sound
PMI = Point of maximal impulse
V₁ = Chest ECG lead 1

	Mitral Stenosis	Mitral Regurgitation	Aortic Stenosis	Aortic Regurgitation	Tricuspid Stenosis	Regurgitation
Inspection	Malar flush, precordial bulge, and diffuse pulsation in young patients.	bulge, and diffuse pulsation in young patients. Usually prominent and hyperdynamic apical impulse to left of MCL.	Sustained PMI, prominent atrial filling wave.	Hyperdynamic PMI to left of MCL and down. Visible carotid pulsations.	Giant a wave in jugular pulse with sinus rhythm. Often olive-colored skin (mixed jaundice and local cyanosis).	Large v wave in jugular pulse.
Palpation	"Tapping" sensation over area of expected PMI. Mid-diastolic or presystolic thrill at apex. Small pulse. Right ventricular pulsation left third to fifth ICS parasternally when pulmonary hypertension is present.	Forceful, brisk PMI; systolic thrill over PMI. Pulse normal, small, or slightly collapsing.	Powerful, heaving PMI to left and slightly below MCL. Systolic thrill over aortic area, sternal notch, or carotids. Small and slowly rising carotid pulse	Apical impulse forceful and displaced significantly to left and down. Prominent carotid pulses. Rapidly rising and collapsing pulses.	Middiastolic thrill between lower left sternal border and PMI. Presystolic pulsation of liver (sinus rhythm only).	Right ventricular pulsation. Occasionally systolic thrill at lower left sternal edge. Systolic pulsation of liver.
Heart sounds, rhythm, and blood pressure	Loud snapping M₁. Opening snap following S₂ along left sternal border or at apex. Atrial fibrillation common. Blood pressurenormal.	M₁ normal or buried in murmur. Prominent third heart sound. Atrial fibrillation common. Blood pressure normal. Midsystolic clicks may be present.	A₂ normal, soft, or absent. Paradoxic splitting of S₂ if A₂ is audible. Prominent S₄. Blood pressure normal, or systolic pressure normal with high diastolic.	S₁ normal or reduced, A₂ loud. Wide pulse pressure with diastolic pressure > 60 mm Hg.	S₁ often loud.	Atrial fibrillation is usually present.
Murmurs Location and transmission	Localized at or near apex. Rarely, short diastolic (Graham Steell) murmur along lower left sternal border in severe pulmonary hypertension.	Loudest over PMI; transmitted to left axilla, left infrascapular area. With posterior papillary muscle dysfunction, may transmit to base.	Right second ICS parasternally or at apex, heard in carotids and occasionally in upper interscapular area.	Diastolic: louder along left sternal border in third to fourth interspace. Heard over aortic area and apex. May be associated with low-pitched middiastolic murmur at apex (Austin Flint) in nonrheumatic disease.	Third to fifth ICS along left sternal border out to apex	As for tricuspid stenosis.
Timing	Onset at opening snap ("middiastolic") with presystolic accentuation if in sinus rhythm. Graham Steell begins with P₂ (early diastole).	Pansystolic: begins with M₁ and ends at or after A₂. May be late systolic in papillary muscle dysfunction.	Midsystolic: begins after M₁, ends before A₂, reaches maximum intensity in mid systole.	Begins immediately after aortic second sound and ends before first sound.	As for mitral stenosis	As for mitral regurgitation
Character	Low-pitched, rumbling; presystolic murmur merges with loud M1 and ends at or after A₂. May be late systolic in papillary muscle dysfunction.	Blowing, high-pitched; occasionally harsh or musical.	Harsh, rough.	Blowing, often faint	As for mitral regurgitation	Blowing, coarse, or musical
Optimum₁ auscultatory conditions	After exercise, left lateral recumbency. Bell chest piece lightly applied	After exercise; diaphragm chest piece. In prolapse, findings most prominent while standing	Patient resting, leaning forward, breath held in full expiration.	Patient leaning forward, breath held in expiration.	Murmur usually louder and at peak during inspiration. Patient recumbent	Murmur usually becomes louder during inspiration
X-ray	Straight left heart border. Large left atrium sharply indenting esophagus. Elevation of left main stem bronchus. Large right ventricle and pulmonary artery if pulmonary hypertension is present. Calcification occasionally seen in mitral valve.	Enlarged left ventricle and left atrium.	Concentric left ventricular hypertrophy. Prominent ascending aorta, small knob. Calcified valve common	Moderate to severe left ventricular enlargement. Prominent aortic knob	Enlarged right atrium only	Enlarged right atrium and ventricle
Electrocardiography	Broad P waves in standard leads; broad negative phase of diphasic P in V₁. If pulmonary hypertension is present, tall peaked P waves, right axis deviation, or right ventricular hypertrophy appears	Left axis deviation or frank left ventricular hypertrophy. P waves broad, tall, or notched in standard leads. Broad negative phase of diphasic P in V₁	Left ventricular hypertrophy	Left ventricular hypertrophy	Tall, peaked P waves. Normal axis	Right axis usual
Echocardiography M mode	Thickened, immobile mitral valve with anterior and posterior leaflets moving together. Slow early diastolic filling slope, left atrial enlargement, normal to small left ventricle	Thickened mitral valve in rheumatic disease; mitral valve prolapse; flail leaflet or vegetations may be seen. Enlarged left ventricle with above-normal, normal, or decreased function	Dense persistent echoes from the aortic valve with poor leaflet excursion, left ventricular hypertrophy with preserved contractile function	Diastolic vibrations of the anterior leaflet of the mitral valve and septum, early closure of the mitral valve when severe, dilated left ventricle with normal or decreased contractility	Tricuspid valve thickening, decreased early diastolic filling slope of the tricuspid valve. Mitral valve also usually abnormal	Enlarged right ventricle prolapsing valve, mitral valve often abnormal
Two-dimensional	Maximum diastolic orifice size reduced, subvalvular apparatus foreshortened, variable thickening of other valves	Same as M mode but more reliable	Above plus poststenotic dilation of the aorta, restricted opening of the aortic leaflets, bicuspid aortic valve in about 30%	Above plus may show vegetations in endocarditis, bicuspid valve, root dilation	Above plus enlargement of the right atrium	Same as above
Doppler	Prolonged pressure halftime across mitral valve; indirect evidence of pulmonary hypertension	Regurgitant flow mapped into left atrium; indirect evidence of pulmonary hypertension	Increased transvalvular flow velocity, yielding calculated gradient. Valve area estimate using continuity equation	Demonstrates regurgitation and qualitatively estimates severity	Prolonged pressure halftime across tricuspid valve	Regurgitant flow mappedinto right atrium and venae cavae; right ventricular systolic pressure estimated