Auscultation Findings in Complex Valvular Heart Disease with Eccentric LVH

Mitral Valve Findings

A holosystolic murmur will be heard best at the apex with radiation to the left axilla due to severe mitral regurgitation, as recommended by the American College of Cardiology 1, 2
A mid-diastolic rumble with presystolic accentuation will be present at the apex due to mild-to-moderate mitral stenosis, according to the American College of Cardiology 1
The first heart sound (S1) may be diminished due to decreased mobility of the mitral valve leaflets, as reported in Circulation 3
The presence of dilated left atrium will contribute to a widely split S2, as noted by the American College of Cardiology 1

An early diastolic decrescendo murmur will be heard along the left sternal border due to aortic regurgitation (grade 3+), as described by the American College of Cardiology 1, 4
Possible soft systolic ejection murmur at the right upper sternal border due to aortic valve sclerosis, according to the American College of Cardiology 2
The second heart sound (S2) may be diminished due to aortic valve sclerosis, as reported by the American College of Cardiology 2
The combination of aortic regurgitation and eccentric LVH may produce a hyperdynamic apical impulse, as noted in Circulation 5

A holosystolic murmur will be heard at the lower left sternal border or xiphoid area that increases with inspiration due to severe tricuspid regurgitation, as described by the American College of Cardiology and Circulation 1, 3
The murmur may be accompanied by a prominent v wave in the jugular venous pulse, as reported in Circulation 3
Right atrial enlargement may contribute to a third heart sound (S3) on the right side, as noted by the American College of Cardiology 1

A soft early diastolic decrescendo murmur may be heard at the left upper sternal border due to mild pulmonic regurgitation, as described in Circulation 6
The pulmonic component of S2 may be diminished, as reported in Circulation 6

A third heart sound (S3) will likely be present due to volume overload from multiple regurgitant lesions and eccentric LVH, as noted by the American College of Cardiology 1
A fourth heart sound (S4) may be present due to decreased ventricular compliance, as reported in Circulation 5
Biventricular enlargement may produce a sustained apical impulse displaced laterally and inferiorly, as described by the American College of Cardiology and Circulation 7, 8

The multiple valvular lesions may create complex auscultatory findings that can mask each other; careful auscultation in different positions is essential, as recommended by the American College of Cardiology 4
The presence of multiple regurgitant lesions may lead to overestimation or underestimation of individual valve lesion severity by physical examination alone, as noted by the American College of Cardiology 9, 4
Auscultation during different respiratory phases is crucial to differentiate right-sided from left-sided murmurs, as reported by the American College of Cardiology 2
Dynamic auscultation with maneuvers may help distinguish between different murmurs, as described by the American College of Cardiology 2

The dilated chambers will influence the auscultatory findings by affecting heart sounds and murmur intensity, as noted by the American College of Cardiology and Circulation 1, 3