Clinical finding (Physical findings) of Mitral stenosis (MS)

Mitral stenosis is most common cardiac valve damage of rheumatic heart disease. This usually occurs at mean years of 19 years following acute rheumatic fever, minimum documented is two years.

Mitral stenosis image from wikipedia

Etiology of MS

· Rheumatic (common)

· Congenital (less frequent)

· Rheumatoid

· SLE

· Hunter-Hurler

· Malignant carciniod

· Methysergide therapy

In approximately 50% of patient with rheumatic heart disease there is no antecedent history of acute rheumatic fever

Rheumatic heart disease pathology and MS

· Commissural fusion 30%

· Cuspal 15%

· Chordae 10%

· All of the above 45%

Clinical findings of MS

from wikipedia

· The clinical findings of MS are sometimes are missed if one is not careful enough during clinical examination to detect mid diastolic murmur (diastolic rumble)

· Diastolic thrill of MS is usually present at apex , and is associated with mid diastolic murmur (rumble)

· Description impulse is tapping type. Which is present in normal space. If this apical impulse is prominent and shifted outwards than one has suspect associated lesion like AR, MR

· Left parasteranal impulse if present suggest pulmonary hypertension

1. Loud first heart sound of MS

a. Cause of loud first heart sound

i. Elevated left atrial pressure in late diastole, allows LV pressure to raise higher than normal before LV-LA cross over pressure takes place

ii. Presence Increasesed LA pressure at end of diastole, keep the mitral leaflets wide open than normal before start of systole

iii. Stiff and non complaint leaflets resonate with increased sound amplitude

b. Soft S1 in patient of MS suggest

i. Calcification of valve leaflets

ii. Associated MR

iii. Associated AR

iv. Masked left ventricular events secondary to RVH

c. Third heart sound is rarely heard in patients of significant MS because early rapid filing of diastole is prevented by mitral stenosis

2. Opening snap of MS

a. Opening snap (OS) due to high left atrial pressure of MS leads abrupt opening of doming mitral valve

b. Opening snap is present only if valve of Mitral leaflets are pliable and absent in calcified leaflets

c. Time interval between second heart sound and opening snap (A2 OS interval)is inversely proportional with severity of MS i.e. severe MS has shorter A2 OS interval

d. A2OS interval of less than 0.08 secs suggest tight MS

e. Long A2OS interval means more than 0.1 secs

f. Differentiating A2 and P2 with Opening snap

i. Standing A2 OS interval increases

ii. On inspiration triple sounds may be heard in presence of OS

3. Mid diastolic murmur (MDM) of MS

a. MDM is starts after the isovolumic relaxation phase i.e. opening of mitral valve

b. Presystolic increase is because of atrial contraction augments flow across stenosed valve

c. Presystolic murmur is absent in , mild MS, AF, left ventricle dysfunction and bradycardia,

d. Severity of MS and MDM

Mitral valve orifice area MVA CM ²	S2-OS interval seconds	Mid diastolic murmur
Mild MS 1.6 -2.5	0.08-0.12	Short MDM or Presystolic murmur
Moderate MS 1.1.-1.5	0.06 – 0.08	MDM with Presystolic murmur with gap Varying length of MDM in atrial fibrillation
Severe less than 1.0	0.04- 0.06	MDM plus Presystolic murmur with out any gap Presystolic murmur present even with atrial fibrillation

e. Causes of increasing in length of MDM

i. Increase Cardiac output

ii. Increase Heart rate

iii. Increase in left atrial pressure

f. Increase Left ventricle end diastolic pressure decreases length of MDM

g. With atrial fibrillation length of murmur varies

h. Valslva maneuver decrease and disappearance of MDM occures

i. Characteristics of MDM

i. Localized to apex

ii. Low pitched (rumbling ) characteristic

iii. Increase with expiration

iv. Increase in left lateral position

v. Decreases with standing

vi. Isotonic exercise increases MDM

j. Left parasteranal heave is more reliable indicator of pulmonary hypertension than palpable P2 in MS

k. Most common cause of early diastolic murmur in left parasteranal area is associated AR than associated PR of pulmonary hypertension

l. If PA systolic pressure goes more than 70mmhg than RV failure occurs which has bad prognosis even with sugary
m. Presystolic murmur is not associated MR
Natural history of MS