Snap, Rubs, Knocks,

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Snap, Rubs, Knocks, PlopChapter 10

• Are G. Talking, MD, FACC
• Instructor
• Patricia L. Thomas, MBA, RCIS

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Outline

• Opening Snap of Mitral Stenosis
• Opening Snap of Tricuspid Stenosis
• Pericardial Friction Rub
• Pericardial Knock
• Mediastinal Crunch
• Tumor Plops

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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

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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

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Where to Listen

• Use the diaphragm of the stethoscope between the
  apex the lower left sternal border at the fourth
  intercostal space

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Associated Findings

• See figure 10-2
• Phonocardiogram of MS Sinus Rhythm
• Opening Snap crescendo diastolic murmur
• Loud first heart sound
• Accentuated presystolic component

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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

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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)

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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

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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

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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

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THE ENDOFCHAPTER 10

• Tilkian, Ara MD Understanding Heart Sounds and
  Murmurs,
• Fourth Edition, W.B. Sunders Company. 2002, pp.
  107-120