Aortic regurgitation, the right-sided valves, mitral valve prolapse, the four classic mimics, prosthetic valves, and the maneuvers that separate them. Part 1 covers mitral stenosis, mitral regurgitation, and aortic stenosis.
Early diastolic decrescendo murmur at the left sternal border, loudest sitting forward in held expiration. A collapsing (water-hammer) pulse and a wide pulse pressure. An Austin Flint rumble at the apex in severe AR.
Severity tracks pulse pressure and murmur duration, not loudness. In acute severe AR the murmur can be short and soft, because LV and aortic diastolic pressures equalize quickly. A quiet murmur in a sick patient is a trap. Most eponymous signs are classic exam material but have modest sensitivity; echo decides.
Holosystolic murmur, left lower sternal border, louder with inspiration (Carvallo's sign).
Large v waves in the JVP; pulsatile, tender liver; RV heave.
Rare, usually rheumatic and usually with mitral stenosis. Diastolic murmur at the left lower sternal border, louder with inspiration; giant a wave in the JVP.
Usually congenital. Ejection systolic murmur at the left upper sternal border; widely split S2 with a soft P2; RV heave.
Usually functional, from pulmonary hypertension. Early diastolic murmur at the left upper sternal border, louder with inspiration (the Graham Steell murmur).
Inspiration increases venous return to the right heart, so right-sided murmurs get louder. One exception: the pulmonic ejection click of valvular pulmonary stenosis softens with inspiration.
Mid-systolic click, often followed by a late systolic murmur, best at the apex. Anything that makes the LV smaller moves the click earlier and lengthens the murmur.
| Maneuver | LV size | Click | Murmur |
|---|---|---|---|
| Standing or Valsalva strain | Smaller | Earlier | Longer |
| Squatting or passive leg raise | Larger | Later | Shorter |
| Mimic | Looks like | The discriminator |
|---|---|---|
| Austin Flint (severe AR) | Mitral stenosis | No opening snap, no loud S1 |
| Carey Coombs (acute rheumatic carditis) | Mitral stenosis | No opening snap; resolves as carditis settles |
| Gallavardin (aortic stenosis) | Mitral regurgitation | Doesn't radiate to the axilla; louder after a post-PVC pause, while true MR is unchanged |
| Graham Steell (pulmonary hypertension) | Aortic regurgitation | Normal pulse pressure; louder with inspiration |
Crisp opening and closing clicks; the closing click is normally the louder. A soft ejection systolic flow murmur in the aortic position is normal.
Sounds like a native valve. A soft ejection murmur (aortic) or early diastolic flow murmur (mitral) can be normal. A new diastolic murmur in the aortic position or a new holosystolic murmur in the mitral position is not.
| Maneuver | Physiology | Louder | Softer |
|---|---|---|---|
| Valsalva (strain) | Less preload | HOCM; MVP (longer) | Most others, including AS |
| Standing | Less preload | HOCM; MVP (longer) | Most others |
| Squatting | More preload and afterload | AS, MR, AR, VSD | HOCM; MVP (shorter) |
| Hand-grip | More afterload | MR, AR, VSD | AS, HOCM |
| Inspiration | More right-heart return | Right-sided murmurs | Pulmonic ejection click |
| Expiration | More left-heart return | Left-sided murmurs, generally | |
| Left lateral position | Apex nearer the wall | MS, MR (use the bell for MS) | |
| Sitting forward, held expiration | Base nearer the wall | AR, pericardial rub |
Valsalva and standing are the cleanest way to separate HOCM from aortic stenosis: HOCM gets louder, aortic stenosis gets softer. Hand-grip softens both, so it can't separate them.
The exam misses a substantial share of significant valve disease (Part 1 covers the primary-care data). Keep the threshold for echo low; the exam tells you what to look for.