Physiology | Heart Valves & Sounds| Dr.

Rene Manalo
October 28, 2014
-

2 AV valves situated between atria and

ventricle
2 Semilunar valves shaped half moon

2 AV valves
- Tricuspid valve right side
- Bicuspid / Mitral valve left side
2 Semilunar valves
- Pulmonic valve
- Aortic valve
FUNCTION:
- Ensure unidirectional flow; ensure cardiac cycle
kept intact, there would be forward flow of
blood, no unidirectional flow, circulation subject
to abnormalities like regurgitation
- When atrial chambers contract, ventricular
chambers should be relaxed.
- Systole / diastole (without specification if atria
or ventricle) ventricular event
ANATOMICAL VS. CLINICAL LOCATION OF VALVES
CLINICAL
- Doesnt totally jive with anatomical location
VALVE
LOCATION
Transmits
its sound
to:
Pulmonic 2nd left ICS, para
sternal line
Aortic
2nd Right ICS,
parasternal line
Tricuspid
Subxyphoid region
(same)
th
Mitral
5 left ICS,
midclavicular line
-

Left side of heart pressure adapted, thicker

Right side volume adapted, thinner
* volume overload in left side, it will fail in
minutes to hours (pulmonary edema - severe
heart failure)
- * increase in pressure at the right side failure
SA node
- Entrypoint at SVC
- Connected to AV node throught 3 internodal
tract (facilitiate the speed of impulse
transmission)
o Bachmann
o Wenckeback

o Thorel
AV node
- Junction rhythm
- Gives off the bundle of His
2 divisions:
o Left Bundle
Left anterior
Left posterior fascicles
o Right Bundle
*lateral leads physiologic q wave: septal
depolarization
SA node atrial depolarization
*0.1 sec PR interval
Bundle of his left first then right (R wave)

AUSCULTATION
2 types:
- Direct auscultation: ears to patients chest
- Indirect auscultation: French physician, Rene
Laennec (through the use of paper)
- Cardiac stethoscope for low frequency sound
Parts:
- Earpiece
- Rubber tubing (25in length)
- Chest piece
o Bell conical part, attuned to low pitch
sound, apply very lightly, much pressure
will deplete the sound, stretches the
skin creating a diaphragm
o Diaphragm for high pitch sound, apply
pressure, double diaphragm effect
HEART SOUNDS
1. Transients
a. S1, S2, S3, S4
b. Clicks, snaps
2. Murmus
a. Turbulence
b. Vortex shedding
Clicks
- Midsystolic click: Lub-click-Dub
o MITRAL VALVE PROLAPSE (BARLOWS
SYNDROME)
o Female, tall, slim, straight back (8F:1M)
o Tx: reassurance, antibiotics,
o Mitral endocarditis
Opening Snap
- MITRAL STENOSIS valvular condition from
RHD
- Sound produced when the mitral valve open.

MEDISIN 2018 | C. Herrera & A. Kosallavat

NORMAL HEART SOUNDS

**Normal Heart sounds are produced on CLOSURE of VALVES

S1 closure of AV valves
S2 closure of SL valves
S3 phase of rapid ventricular filling
S4 atrial contraction; ATRIAL KICK

Fixed S2 splitting
- in both inspiration & expiration will have S2
splitting
- due to ASD (Atrial Septal Defect)

S1
-

LUBB
Longer
Lower pitch
Louder at the apex

S3
-

S2
- DUP
- Shorter
- Higher pitch
- Softer at the apex
**Insert drawing.
**ventricular diastole
- Coronary artery fills up
Systolic time is preserved. Diastolic time shortened in
tachycardia
S1 and S2 determines the CO
At the base, the same except intensity of sound
- S1 becomes softer, S2 becomes louder
CONTINUATION: OCTOBER 29, 2014
S1- increases its intensity when the heart rate is fast
(tachycardia)
- Abnormally increased: MITRAL STENOSIS
- Decrease intensity is normal when HR is slow
- Abnormally decreased: MYODCARDIAL
ISCHEMIA, CHF
S2

S1

P2
A2

pulmonic component appearing first, followed

by aortic component
due to LBBB

S1

P2
A2

Due to inspiration there is increase venous return in the

right side, causes the splitting
Widened S2 splitting
- present on expiration and more pronounced
(further delay) during inspiration
- due to RBBB QRS will look like M
Paradoxical S2 splitting
- splitting on expiration
- becomes single on inspiration, the increase in
venous return

normally old upto about 18y/o

most intense time during (preschool)
presence in adult, denotes heart failure (earliest
sign)
VENTRICULAR GALLOP (abnormal)
protodiastolic gallop (early in diastole): Heart
Failure
KENTUCKY
S2 is near S3

S4
-

Should not be heard by the age 18

ATRIAL GALLOP / PRESYSTOLIC GALLOP
S4 near S1; distorts the quality of S1 LUBBA DUP
Contraction of the atrial chamber
TENNESSEE

SUMMATION GALLOP
- All gallops are present LUBBA DUPPA
- MISSISSIPPI
Left atrium left ventricle SV delivered, the aortic
valve closes; not completely drained, then end systole,
Mitral valve silently opens by pressure gradient the
pressure is transferred. LOST!
LVEDP, atrial chamber contracts, push the residual
volume (S4).

MURMURS
2 mechanisms:
1. Turbulence
-Vessel, laminar flow, disruption to normal flow
-HEMIC MURMURS (temporary), in cases of
mod to severe anemia, pregnancy,
thyrotoxicosis, AV fistulas (abnormal connection
between artery and vein)
2. Vortex shedding
-EDDYING

MEDISIN 2018 | C. Herrera & A. Kosallavat

**Systolic murmurs, may or may not be

abnormal diastolic murmurs are ALWAYS
ABNORMAL

STILLs MURMUR
Systolic murmurs, best heard in pulmonic area
Musical quality and vibratory quality
Usually heard in children 4-5 y/o

**most murmur occur mostly in valvular defect and..,

the intensity of murmurs inversely prop to the defect
(the louder the murmur, the smaller the defect)
Strep thoat, stimulates the immune system, the
reaction is delayed, produced streptolysin O, destroys
the strep.
- Rheumatic arthritis
- RHD: Carditis
The valve becomes deform, the initial lesion is
incompetent, there is insufficiency, causes regurgitation
Once it heals, produced stenosis (FISH MOUTH lesion)
-

Systolic Semilunar valve Stenosis

Systolic AV valve Regurgitation
Diastolic Semilunar valve regurgitation
Diastolic AV valve Stenosis
Systole and Diastole (machinery murmur) :
GIBSONs MURMUR Patent ductus arteriosus

MEDISIN 2018 | C. Herrera & A. Kosallavat