An argument for reviving the disappearing skill of cardiac auscultation
Bedside clinical diagnosis is an increasingly underappreciated art and skill. For example, contemporary medical students, residents, fellows, and cardiologists have been shown to lack competency in cardiac auscultation,1,2 despite warnings from older physicians trained in an era when the physical examination was valued.3,4
However, echocardiography has given physicians the ability to visually evaluate cardiac function noninvasively and quickly. With advanced technology, does this modern decline in auscultatory skills matter? And specifically, can inexpert cardiac auscultation lead to the inadequate evaluation of valvular heart disease and subsequently to an incorrect recommendation for surgery?
Although the ill consequences for patient care would be difficult to prove, we strongly believe, on the basis of our experiences in a busy cardiovascular surgery clinic in a tertiary care center, that the answer to both questions is yes.
Here, we present three recent scenarios from the clinic of a senior cardiac surgeon who regards the skillful use of his stethoscope as being as important as the echocardiogram. These scenarios highlight how the clinical examination can complement echocardiography in the evaluation of valvular heart disease and how it can affect important management decisions.
SCENARIO 1: SEVERE AORTIC INSUFFICIENCY?
A 53-year-old woman with Turner syndrome (gonadal dysgenesis) suffered an acute ascending aortic dissection requiring resuspension of the aortic valve and replacement of the ascending aorta. Her postoperative course was complicated by pneumonia, respiratory failure, and prolonged mechanical ventilation requiring tracheostomy.
Three months after she completed her convalescence at a skilled nursing facility, she presented to her cardiologist with progressive shortness of breath that severely limited her activity. Echocardiography showed moderately severe aortic insufficiency, and she was referred for aortic valve replacement.
At the cardiac surgery clinic, she reported a further decline in her functional status, with dyspnea during minimal exertion. On physical examination, however, there was no evidence of significant aortic incompetence, ie, no widened pulse pressure, left ventricular heave, or diastolic murmur. A cardiologist specializing in echocardiography reviewed the echocardiogram from the referring physician and found that the appearance was more consistent with mild to moderate aortic insufficiency.
Because her profound symptoms were out of proportion with the degree of aortic insufficiency that was observed, further workup including pulmonary function testing was pursued to find another cause; she was subsequently found to have significant tracheal stenosis, likely related to her tracheostomy. Surgery to remove scar tissue resulted in marked improvement of her symptoms.
SCENARIO 2: SEVERE MITRAL REGURGITATION?
A 67-year-old man who had undergone homograft aortic valve replacement 13 years ago underwent routine echocardiography at another hospital. The test showed a large regurgitant jet and backward flow in the pulmonary veins, indicating moderate to severe mitral regurgitation. Also noted was a mildly decreased ejection fraction of 45%. Because of these findings, he was referred for consideration of mitral valve surgery.
At presentation, he had essentially no symptoms and had a very active lifestyle that included regular biking and running. A physical examination that included auscultation in the left lateral decubitus position noted only a soft systolic ejection murmur at the left upper sternal border.
In view of these findings, repeat echocardiography was ordered and revealed mild mitral regurgitation with normal left atrial and ventricular dimensions, as well as normal left ventricular systolic function. These findings were markedly different from those obtained at the other hospital. The murmur was thought to likely represent flow across the base of the homograft valve. These results confirmed our clinical suspicion that there was no indication for mitral valve surgery.
