Differential diagnosis for specific signs and valvular lesions. these lists should ideally be learnt to parrot fashion.
Explaining each rare syndrome is beyond the scope of this podcast but remember if you are going to list it as a differential you need to know what it is!
When giving a list of differentials to the examiners start with the commonest, it often helps to divide the answer into common and rare causes to remind yourself.
Ejection Systolic Murmur: Aortic stenosis/ Pulmonary Stenosis, Aortic sclerosis, HOCM, ASD.
(ASDs cause a soft ESM due to abnormally increased flow across the pulmonary valve from a left to right shunt, the murmur is not the passage of blood between the atria! ASD can cause functional TR and a pansystolic murmur due to RV overload. )
Pansystolic Murmur: Mitral regurgitation & Tricuspid regurgitation. VSD. ASD
Diastolic Murmur: Early: Aortic regurgitation/ Pulmonary Regurgitation
Mid: Mitral & Tricuspid stenosis
Don’t forget that Infective endocarditis can also fall within the differential for any new murmur but more commonly right sided lesions.
Causes of specific valvular lesions:
Aortic stenosis: Calcific degeneration (commonest), congenital bicuspid valve, post rheumatic fever, IE, Congenital, hyperuricaemia & pagets disease.
Aortic Regurgitation: Acute: IE, aortic dissection, acute rheumatic fever, failing AVR, ruptured sinus of valsalva.
Chronic: Bicuspid aortic valve, Marfans syndrome, rheumatic fever and IE, syphilis and seronegative arthritidies (eg. Ankylosing spondylitis etc).
Mitral stenosis: Rheumatic fever (commonest >%90), degenerative severe annular calcification, congenital (can be in isolation or syndrome eg. Shones syndrome or cortriatriatum) & non-valvular causes (LA myxoma, IE with large thrombus or vegetation)
Acute: IE, rupture of chordae tendinae (Myocardial infarction, IE or rheumatic fever) or trauma.
Chronic: IE, connective tissue disorders (Marfans syndrome, ehlers danlos syndrome), MVP, RA, SLE (libmann-sachs endocarditis), cardiomyopathies and functional (secondary to LV dilatation and stretching of the MV annulus).
Associations with MVP: PKD, cardiomyopathy, WPW syndrome, PDA , Marfans syndrome and muscular dystrophies.
Tricuspid stenosis: Carcinoid syndrome, congenital (partial tricuspid atresia), rheumatic fever (rare often left sided lesions)
Acute: IE & Trauma
Chronic: Pulmonary HTN, IE, ebsteins anomaly, Rheumatic fever, carcinoid syndrome)
A point important to note is that IE caused by IV drug use usually causes right sided lesions. This is due to irritants/ bulking agents the drugs are mixed with that damage the right sided valves, thus making these valves more prone to host infections. The IV drug use then gives a mechanism for bacteria to enter the venous blood stream and infect these valves. It is not the drugs themselves that damage the valves!
Pulmonary Regurgitation: Pulmonary HTN: primary and secondary eg Cor-pulmonale (with secondary being the commonest cause) post repair of Tetralogy of Fallot (ie. if pulmonary valvotomy done),Congenital lack of pulmonary valve, Marfans syndrome (rare), IE, carcinoid or rheumatic valvular disease
Pulmonary stenosis: Congenital (often from maternal rubella infection =commonest), Rheumatic fever (usually occurs along with other valvular lesions) Carcinoid syndrome (rarely occurs in carcinoid syndrome)
VSD: Congenital, post MI (often 24-72hrs: requires early surgical intervention)
ASD: Congenital (associations: downs syndrome, kleinfelters, noonans syndrome an MVP)
Coarctation of the aorta associations:
Cardiac: Bicuspid aortic valve, PDA, VSD, aortic dissection,
Non-cardiac: turners syndrome, berry’s aneurysm, NF Type 1, Marfans syndrome.
Written by Dr Thomas Craven
Resources used to write this document are listed in the references section of this webpage