percussion of heart.pptx

percussion of heart

1. Azerbaijan Medical University Department of clinical skills Halil İbrahim ŞEFİK 220i-6a MPF2

2. Anatomy The heart is enclosed in the chest cavity, within the rib cage, which allows for identifying the approximate location of the heart using the sternum and ribs as points of reference. Roughly 1 centimeter (cm) from the right sternal line, along the upper border of the 3rd right costal cartilage is the first point. Continuing to about 2.5 cm from the left lateral sternal line along the lower border of the 2nd left costal cartilage is the second point, which then forms the top boundary.

3. Anatomy The next point is found approximately 2 cm to the right of the sternum along the interspace between the 6th and 7th rib on the right, where the cartilage joins the sternum. The fourth and final point is found about 9 cm to the left of the midsternal line, and corresponds to the apex of the heart. Joining these points will form the other 3 borders of the heart . The location where the 4 main heart valves can be heard is divided into the aortic area, pulmonic area, tricuspid area, and mitral area.

4. Anatomy The aortic area is found in the 2nd intercostal space to the right of the sternum. The pulmonic area is found in the 2nd intercostal space to the left of the sternum. The tricuspid area is found in the 4th intercostal space to the left of the sternum, where other right heart sounds will also be heard. Finally, the mitral area is found in the 5th intercostal space along the mid-clavicular line, where left heart sounds can also be heard. These 4 areas can be remembered by the mnemonic “All Physicians Take Money” or “All Patients Take Meds”. Alternatively, some use the mnemonic Apartment M2245 (APT M2245), for the locations (2 right) aortic, (2 left) pulmonic, (4) tricuspid, and (5) mitral. Another important auscultation point is known as “ Erb’s point” which is found at the 3rd left intercostal space, along the left sternal border, between the pulmonic and tricuspid areas.

5. Heart percussion Main goals of heart percussion are: 1. Disclosure of ventricular and auricular dilation; 2. Disclosure of vascular bundle dilation.

6. Defining of relative cardiac dullness borders. At first right, left and upper borders of relative cardiac dullness are defined. It is necessary to obtain beforehand an indirect impression about the level of diaphragm standing which influences the results of percussion defining of relative cardiac dullness size. For this purpose the lower border of the right lung is defined along the midclavicular line which is normally located at the level of rib VI The right border of relative cardiac dullness, formed by the right atrium (RA), is found by percussing one rib above the found lower lung border (usually in the IV intercostal space), moving vertically placed pleximeter finger strictly along the intercostal space. Normally it situated at the right sternum edge or 1 cm laterally. The left border of relative cardiac dullness formed by the left ventricle (LV) is defined after preliminary palpation of the apical impulse, usually in the V intercostal space, moving from anterior axillary line towards the heart. Normally it situated medial to the midclavicular line for 1-2 cm. The upper border of relative cardiac dullness, formed by auricle of left atrium and pulmonary artery trunk is defined by percussing from top to bottom, 1 cm lateral from left sternal line (but not along left para-sternal line!). Normally it situated at the III rib level.

7. No rmal borders of the absolute cardiac dullness: right - in the IV intercostal space along the left edge of the sternum, the upper - level of the lower edge IV R. at the left parasternal line, left - 1-2 cm medially from the left border of relative cardiac dullness. Changes of heart dullness borders may be caused by extra cardiac reasons. So, while high diaphragm level heart takes a horizontal position that leads to increasing of the transverse heart size. At low diaphragm level heart takes a vertical position, and, accordingly, its transverse size becomes less. Pleural fluid or free pleural air in one of the pleural cavities brings to displacing of .the cardiac dullness borders to the healthy side, atelectasis or lung shrinking, fibro thorax – to the sore side. Area of superficial cardiac dullness sharply decreases or disappears at the emphysema and increases at the lung shrinking. Increase of superficial cardiac dullness area also occurs in heart ante displacement by mediastinal tumour , pericardium effusion, right ventricle dilation. Relative cardiac dullness borders are displaced because of the heart chambers dilation. Relative dullness borders displacement to the right is caused by right atrium and right ventricle dilation. Relative dullness is displaced upwards because of left atrium and pulmonary artery trunk dilation. Relative dullness borders displacement to the left is the result of left ventricle dilation. It is necessary to remember, that sharply dilated and hypertrophied right ventricle shoving back the left ventricle also can displace relative dullness border to the left. Aortic dilation leads to dullness diameter increase in the 2nd intercostal space.

8. Measurement of heart diameter. For measurement of heart diameter the distances from right and left borders of relative cardiac dullness to midsternal line are defined. Normally these distances make respectively 3-4 cm and 8-9 cm, and heart diameter makes 11-13cm .

9. Defining of vascular bundle borders. The vascular bundle including aorta, vena cava superior and pulmonary artery is not simple to percuss. Soft percussion is applied, moving vertically placed pleximeter finger along the II intercostal space on the right and on the left towards the sternum. Normally vascular bundle borders coincide with right and left edges of the sternum, its width doesn't exceed 5-6 cm.

10. Defining of heart configuration For defining of heart configuration the borders of right and left contours of relative cardiac dullness are additionally defined by percussing in the right III intercostal space and in the left III and IV intercostal spaces. Having connected all the points corresponding the borders of relative cardiac dullness, one can obtain the idea about heart configuration. Normally an obtuse angle is clearly defined along the left heart contour between the vascular bundle and the left ventricle - the socalled waist of the heart. The arc of the right contour of the heart in norm –vena cava superior– on the edge of the sternum to R. III, right atrium in the 3-4 intercostal spaces 1 cm outwards from the right edge of the sternum. The angles of the right contour of the heart in norm – angle between vena cava superior and right atrium and between the right atrium and diaphragm in the 5 intercostal space from the sternum. The arc of the left contour of the heart in norm - I intercostal space at the edge of the sternum - aortic arch, II intercostal space at the sternum – the arc of the pulmonary artery, level III R. over the edge of the sternum arc of the left atrium, below the arc of the left ventricle. The "waist" of the heart is the angle between the vascular bundle and the arc of the left ventricle. The vertex of this angle- left atrium auricle . With the increase of LP waist heart ''smoothed", while increasing the LV – "stressed".

11. Defining of heart configuration Defining of heart configuration. For defining of heart configuration the borders of right and left contours of relative cardiac dullness are additionally defined by percussing in the right III intercostal space and in the left III and IV intercostal spaces. Having connected all the points corresponding the borders of relative cardiac dullness, one can obtain the idea about heart configuration. Normally an obtuse angle is clearly defined along the left heart contour between the vascular bundle and the left ventricle - the socalled waist of the heart. The arc of the right contour of the heart in norm –vena cava superior– on the edge of the sternum to R. III, right atrium in the 3-4 intercostal spaces 1 cm outwards from the right edge of the sternum. The angles of the right contour of the heart in norm – angle between vena cava superior and right atrium and between the right atrium and diaphragm in the 5 intercostal space from the sternum. The arc of the left contour of the heart in norm - I intercostal space at the edge of the sternum - aortic arch, II intercostal space at the sternum – the arc of the pulmonary artery, level III R. over the edge of the sternum arc of the left atrium, below the arc of the left ventricle. The "waist" of the heart is the angle between the vascular bundle and the arc of the left ventricle. The vertex of this angle- left atrium auricle . With the increase of LP waist heart "smoothed", while increasing the LV – "stressed".

12. Mitral configuration I - W aist heart smoothed at the expense of hypertrophy of the left atrium, the vascular bundle can be extended due to the dilatation the pulmonary artery, it is possible to laterally shift the right border of relative cardiac dullness due to right ventricle hypertrophy with the development of pulmonary hypertension; the reason for the configuration is mitral stenosis.

13. Mitral configuration II - T he reason for the configuration is mitral incompetence. Mitral valve incompetence ( insufficientia valvulae mitralis ) appears in that cases when mitral valve on left ventricle systole incompletely closes left atrioventricular ostium and blood regurgitates from the ventricle to the atrium. Mitral incompetence may be organic and functional. Organic mitral incompetence more frequently appears as a result of rheumatic endocarditis due to which connective tissue develops in valve leaflets and later on it is wrinkled and causes shortening of leaflets and attached chordae tendinae . As a result of these changes valve edges during systole closes incompletely, forming a chink through which in ventricle contraction the part of blood regurgitates into the left atrium. Rarely wrinkling of valve leaflets and shortening of chordae tendinae develops as a result of atherosclerosis. In functional or relative mitral incompetence mitral valve is not changed but it ’ s ostium is enlarged and valve leaflets close it incompletely. Relative incompetence may develop owing to left ventricle dilatation in myocarditis, myocardidystrophy , myocardiosclerosis , when circular muscle fibers, forming muscle ring around the atrioventricular ostium weaken, and also in papillary muscles damage.

14. Hemodynamics abnormalities A little narrowing of aortic orifice doesn’t cause significant circulation alteration. If the degree of stenosis is high, during systole the left ventricle empties incompletely, as all blood volume has no time to pass across narrow orifice into aorta. On diastole normal blood volume from the left atrium adds to this residual blood portion, that leads to left ventricle overfilling and pressure rising within it. This abnormality of intracardiac hemodynamics is compensated by left ventricle overwork, and causes its hypertrophy . On percussion the displacement of relative dullness borders to the left and aortic heart configuration (with accentuated cardiac waist), caused by left ventricular hypertrophy are detected.

15. insufficientia valvulae aortae ‘‘ Aortic incompetence ’’ is valve disease in which the semilunar cusps close incompletely the aortic orifice and during diastole blood regurgitates from aorta into left ventricle . Aortic regurgitation occurs if the aortic valve ring dilates , as a result of dissecting aneurysm , ankylosing spondylitis or syphilis for example , or if the valve cusps degenerate , such as after rheumatic fever , atherosclerotic lesion or endocarditis .

16. Trapezoida l configuration of the heart I n aortic incompetence during diastole blood comes in the left ventricle not only from the left atrium but regurgitates from aorta to. It causes left ventricle overfilling and stretching on diastole. During systole left ventricle contracts with grater force to eect into aorta increased stroke volume. Left ventricle overwork leads to its hypertrophy, and increase of systolic blood volume in aorta causes its dilatation. Sharp fluctuation of blood pressure within aorta during systole and diastole is characteristic for aortic incompetence. Increased as compared with normal blood volume within aorta during systole causes increase of systolic blood pressure, and as a part of blood volume regurgitates into ventricle during diastole, diastolic pressure rapidly decline. T he heart has a trapezoid shape, waist of the heart, angle between vena cava superior and right atrium and angle between right atrium and diaphragm "disappear'' the reason of configuration is hypopericardium .

17. Drip" configuration of the heart - T he left and right border of cardiac dullness is shifted medially, the area of cardiac dullness is diminished, the heart becomes "drip" form, cause - emphysema of the lungs .

18. Thanks for your attention 

19. References https://www.kenhub.com/en/library/anatomy/percussion-and-auscultation-of-the-heart https://www.ulsu.ru/media/documents/Internal_diseases_propedeutics._Part_II._Diagnostics_of_cardiovascular_diseases.pdf