00:01
Squatting, we talked about this
with overview changes in murmur.
00:05
With squatting rapid,
you are going to increase venous return.
00:08
Most murmurs will increase,
what is the big exception
that you are going
to predict for me?
Hypertrophic obstructive
cardiomyopathy,
more amount of
blood in your heart.
00:17
Remember.
00:18
HOCM comes under the division of the
category of hypetrophic cardiomyopathy
and the most common hypertrophic
cardiomyopathy will be the obstructive type
with what kind of hypertrophy
of the interventricular septum?
Asymmetrical.
00:35
Asymmetrical.
00:37
Valsalva, what happens?
I have been saying this
phase over and over again.
00:42
You have your closed epiglottis for
which you are breathing out or expiring.
00:46
As you do so you increase
your thoracic pressure.
00:48
You are going to squeeze
the pulmonic capillaries
and you go into phase II.
00:51
With phase II, you decrease the amount
of blood returning to the left side
and so, therefore, the intensity of
most of the murmurs is going to decrease
or are going to decrease.
01:01
Now, something that I wish
to bring your attention.
01:04
Yet once again what Valsalva,
tell me about MVP, mitral valve prolapse.
01:08
Four components, what are they?
S1, S2. Two down, two to go.
01:13
Click and murmur,
that is your pathology.
01:15
When you do valsalva, you have
decreased amount of blood to the heart.
01:18
What happens to that click?
That click gets closer to S1.
01:21
It is a not a delayed click,
but a shortened click, isn' it?
An early click.
01:27
What then happens to the murmur?
It is now lengthened, right.
01:30
What happens to the
intensity of the murmur?
It increases at valsalva.
01:33
When we do exercise
or rapid squatting
and I showed you pictures before
in which you would then have
increased amounts of blood.
01:40
The click within get closer
to S2 or it is delayed
and the murmur shortened.
01:44
If you understood or if you missed
that concept, go back and review.
01:47
If you have got it
down, let us move on.
01:50
Let's not waste time.
01:51
Let us be efficient.
01:52
The two exceptions
are exactly here.
01:54
Two exceptions are
systolic murmur right,
here in which with valsalva,
with hypertrophic obstructive,
it is going to get worse.
02:03
Mitral valve prolapse,
it is going to become longer.
What is the murmur?
What about the click?
It gets early.
02:10
Exactly what we
just went through.
02:11
Let us continue.
02:12
Isometric handgrip,
what is happening here?
It is the fact that when you do a
handgrip, you are increasing your TPR.
02:18
When you increase your
TPR, then now here,
who haven't talked about this.
02:22
Well, it is the first time we are
seeing this, talked about handgrip,
but not in reference to
the following murmurs.
02:29
So murmurs of mitral regurg.
02:31
So first and foremost,
clenching of fist.
02:35
You constrict your arterials,
increase TPR, increase afterload.
02:39
There is more blood, where?
Left in your left ventricle
because of increased afterload,
increased resistance.
02:43
We can all agree upon that.
02:45
Let's say that you
have mitral regurg.
02:46
You tell me quickly mitral
regurg difficulty with?
Closing.
02:50
When do your mitral valve close?
During systole.
02:53
It causes systolic
murmur between S1 and S2.
02:56
What kind of murmur?
All systolic.
02:57
You should be able to go
through that quickly
and you will.
03:01
These are steps that you have to
take a medicine every single time.
03:04
The more organized
your thoughts are,
the faster that you
can run through them,
and, therefore, when an attending
or an exam asks you a question,
you arrive at the answer
in a very efficient
and quick manner.
03:15
I know it is never going
to leave you. Never.
03:18
Ventricular septal defect,
aortic regurgitation
with all of these
with a handgrip,
you are going to increase intensity
of the murmur because of the backup.
03:26
You can’t move forward.
03:27
Increase the afterload,
increase resistance.
03:30
Handgrip versus hypetrophic
cardiomyopathy, aortic stenosis.
03:34
Pay attention.
03:36
Hypertrophic cardiomyopathy,
asymmetrical hypetrophy,
outflow tract is very
very compromised.
03:43
Thus by handgrip,
you increase afterload,
the seperation of the outflow
tract becomes increased.
03:49
Thus, the intensity of the
murmur is going to decrease.
03:52
Tell me about aortic stenosis?
Normal gradient is high between
left ventricle and the aorta
to ensure unidirectional
flow, correct?
Now you do a handgrip,
what happens?
Less blood passing across
this stenotic aortic valve.
04:07
What happens to the murmur?
Decrease in intensity.
04:11
Tell me about MVP.
04:12
You have more blood
left in your heart.
04:14
What happens to that click?
It gets closer to S2.
It is delayed.
04:18
What happens to murmur?
Decreased intensity.
There you have it.
04:21
That mind right
there for handgrip
probably one of the most
important one for manuvers
because students tend to get
that wrong over, over and over.
04:29
You understand the pathophys.
04:30
There is no way that they
are going to shake you.
04:33
You are invincible, my friend.
04:37
Increased afterload delays left
ventricular emptying in HCM.
04:41
In aortic stenosis,
turbulent flow reduced as well due to
reduced pressure gradient.
04:47
Nice little table for you to take a
look at all the different maneuvers.
04:50
I'm just going to show you one
little point for each on these lines
and then your own time
make sure that you're clear
about how to interpret this.
04:58
If you've understood
everything I said,
this table becomes
absolutely invaluable.
05:04
Lying down,
tell me about venous return.
05:06
Increased.
05:07
It's going to increase the
murmur of every single murmur,
except for HOCM.
05:14
And tell me about MVP,
the click is delayed,
the murmur is decreased.
05:18
Next,
sudden standing, where is my blood?
Down in legs.
05:21
So therefore,
decrease venous return.
05:24
So therefore,
tell me about HOCM.
05:27
The outflow tract gets worse,
increase intensity.
05:30
What about MVP when there's
decrease amount of blood?
The click gets closer to S1,
early click,
long-length in murmur.
05:36
Let's move on.
05:37
Squatting,
increased venous return.
05:39
Do you see the point now?
You take a look at
squatting, you're lying down.
05:44
Pretty similar.
05:46
Valsalva.
05:47
Take a look at valsalva
in standing up,
pretty similar, huh?
Post PVC beat.
05:55
So this is a little bit
more detail in terms of
your premature
ventricular type of issue.
06:00
Hand grip.
06:01
With hand grip,
you're going to increase afterload.
06:03
There is more blood that's
going to be left inside my
heart.
06:07
Now, be careful here.
06:09
What stenosis of aortic and
pulmonic with hand grip,
it's about the
pressure gradient.
06:14
Therefore, the intensity
murmur is going to decrease.
06:16
In HOCM, hand grip,
more blood in my heart.
06:19
So therefore,
more separation of the outflow tract.
06:22
MR, MS and AR in those cases,
you are then going to
increase intensity murmur,
especially MR and AR.
06:31
Amyl nitrite,
now where is my blood?
With amyl nitrate, what ends up happening
is that you have decreased preload
because you have
decreased venous return.
06:39
Think of nitrate as causing decreased
preload due to vein no dilation.
06:44
So therefore, there's more pooling
of your blood in your veins,
not your heart, the veins.
06:50
So you have more blood in your
veins less than your heart.
06:53
What then happens to hypertrophic
obstructive cardiomyopathy,
the obstruction?
Well, it gets worsen,
increase intensity.
07:01
Clear.
07:03
So these are things that
you're paying attention to,
as you're going through
the various maneuvers.
07:07
You want to try to get a good
idea of at least some of the ones
that I just mentioned
here, for sure.
07:12
And then anything beyond that,
well, you take a look
at on your own time.
07:15
And you do this every so often,
you do this to reinforcement.
07:18
And before you know it,
this stuff is coming to you like
it's instinct.
07:23
Trust me.