Combined lesion Mitral stenosis (MS) and Aortic stenosis (AS)

Combined lesions MS and AS are usually secondary to rheumatic heart disease. In this combination  even AR association is not uncommon
Apart from Rheumatic etiology for MS and AS combination is in congenital lesion, Shone's complex  MS, AS and COA
Rheumatic heart disease causing isolated AS is rare
In patients with AS and MS, both together lead to decrease in cardiac output, which is much more than isolated AS or MS.
Pulmonary congestion signs of MS are not affected so patients present with dyspnea pulmonary edema. When reactive pulmonary hypertension develops signs of pulmonary congestion may disappear and signs of right heart failure may appear.
Physical findings
1.      Signs of AS are masked in presence of severe MS. Ejection systolic murmur may decrease in intensity, Apical impulse is less than heaving
2.      In an unusual patient Signs of MS i.e. S1 may not be loud and opening snap and MDM may not be heard, sparing Ejection systolic murmur of AS
3.      Carotid upstroke is delayed
1.      LVH may not be present in ECG
2.      Left atrial enlargement and Atrial fibrillation is as common as in isolated MS
3.      RVH may not be seen in ECG
Chest X ray
1.      Similar to isolated MS and AS
2.      Aortic valve calcification and post stenotic dilatation of aorta is more common than isolated AS
1.      Due to decreased cardiac output Doppler gradient across both mitral and aortic valve will be decreased. So under estimate the severity by Doppler.
2.      2 D planimetry for aortic valve, over estimates severity of AS as valves may not open.
3.      For aortic valve area estimation continuity equation is useful

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