Transcript Document

Snap, Rubs, Knocks, & Plop
Chapter 10
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS
Outline
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Opening Snap of Mitral Stenosis
Opening Snap of Tricuspid Stenosis
Pericardial Friction Rub
Pericardial Knock
Mediastinal Crunch
Tumor Plops
Opening Snap of Mitral Stenosis
• Heard in Early Diastole a characteristic sign of
mitral stenosis
• Sharp, medium frequency, & moderately loud
sounds
• Early diastole at the end of the isometric
relaxation period
• Occurs .06 to .12 sec after the A2
• Severe Stenosis-LA pressure is higher & forces
the valve quickly forward to an early snap
Causes
• In mitral stenosis, scarring & thickening of
the valve leaflet edges has bound them
together; the most common cause is
rheumatic heart disease
• Opening snap is a result of the anterior
leaflet becoming taut, and snaps to a halt,
producing a sharp early diastolic sound that
is diagnostic of mitral stenosis
Where to Listen
• Use the diaphragm of the stethoscope
between the apex the lower left sternal
border at the fourth intercostal space
Associated Findings
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See figure 10-2
Phonocardiogram of MS & Sinus Rhythm
Opening Snap crescendo diastolic murmur
Loud first heart sound
Accentuated presystolic component
Intensity of the Snap
• Mitral Stenosis the opening snap is almost
always heard
• Moderately calcified valve leaflets
– Soften opening snap
• Severely calcified valve leaflets
– No opening snap
• Physical activity & opening snap
– LA mean is high louder opening snap
• Aortic insufficiency
– May decrease the intensity of the OS because of the
reduced rate of anterior motion of the mitral leaflets
in early diastole
Pericardial Friction Rub
• Inflammation of the pericardial membrane or pleural sac at
the 3rd and 4th interspace at the left sternal border. Louder
during inspiration
• Scratchy, like sandpaper being used, a match being struck,
or leather squeaking
• Sound present when the epicardial & pericardial surfaces,
roughened by inflammation, slide over one another during
atrial & ventricular systole & during the passive motion of
rapid ventricular filling
• 3 components
– Atrial Systolic (A)
– Ventricular Systolic (V)
– Ventricular Diastolic (D)
Percardial Knock
• Sharp, high-pitched sound present in 90% or
more of patients with constrictive pericarditis
• Heard in diastole
• Occurs .09 to .12 sec after S3
• See figure 10-5
• Occurs after Heart Surgery, radiation therapy,
viral infection, TB pericarditis
• Diaphragm of the stethoscope listen at the
lower left sternal border
Tumor Plops
• Clues to a Myxoma
– Cardiac silhouette on X-Ray consistent with
atrial enlargement
– An ECG showing signs of LA enlargement
– Light-headedness
– A very short presystolic murmur
– Extra sound in diastole
Tumor Plops
• Left Atrial Tumors
– Loud, low-frequency thud heard in early diastole
& caused by abrupt movements of the tumor
inside the LA
– It strikes the wall of the chamber or comes to a
sudden halt as the pedicle reaches the limit its
stretch
• Mitral Valve Vegetation
– Echo demonstrates a physical movement of
vegetation across the mitral valve apparatus
– Listen with the diaphragm of the stethoscope at
the point of PMI with patient in the left lateral
position
THE END
OF
CHAPTER 10
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp. 107-120