Mitral stenosis physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Mitral stenosis is associated with a rumbling diastolic murmur and an opening snap.
Vitals
- Tachycardia may be present if there is a reduction in cardiac output
Head
There is sometimes a mitral facies with patches of pink and purple on the face due to peripheral vasoconstriction
Neck
- Jugular venous distension
- V waves with tricuspid regurgitation
Heart
The Opening Snap of Mitral Stenosis
The closing of the mitral valve and the tricuspid valve constitutes the first heart sound (S1). It is not actually the valve closure which produces a sound but rather the sudden cessation of blood flow caused by the closure of the mitral and tricuspid valves. The mitral valve opening is normally not heard except in mitral stenosis as the opening snap. It is a high pitched additional sound that may be heard after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve. Initially, an OS is heard because there is an increased gradient between the LA and LV and S1 is loud. As the valve calcifies and LA pressure increases, S1 becomes softer and the OS moves closer to S2.
Mid-diastolic rumbling murmur heard after the opening snap
The murmur is best heard at the apical region and is not radiated. Since it is low-pitched it should be picked up by the bell of the stethoscope. Rolling the patient towards left, as well as isometric exercise will accentuate the murmur.
<youtube v=E0fDFsmVQfY/> An opening snap
- S1:The first heart sound is unusually loud and may be palpable due to the increased force of the closing of the mitral valve.
- S2:If pulmonary hypertension secondary to mitral stenosis is severe, the P2 (pulmonic) component of the second heart sound (S2) will become loud.
- S3: Flow of blood into the heart during rapid filling is not normally heard except in certain pathological states where it constitutes the third heart sound (S3).
Murmur
The mitral valve opens when the pressure in the left atrium is greater than the pressure in the left ventricle. This happens in ventricular diastole (after closure of the aortic valve), when the pressure in the ventricle precipitously drops. In individuals with mitral stenosis, the pressure in the left atrium correlates with the severity of the mitral stenosis. As the severity of the mitral stenosis increases, the pressure in the left atrium increases, and the mitral valve opens earlier in ventricular diastole. An opening snap which is a high pitched additional sound may be heard after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve. The mitral valve opens when the pressure in the left atrium is greater than the pressure in the left ventricle. This happens in ventricular diastole (after closure of the aortic valve), when the pressure in the ventricle precipitously drops. In individuals with mitral stenosis, the pressure in the left atrium correlates with the severity of the mitral stenosis. As the severity of the mitral stenosis increases, the pressure in the left atrium increases, and the mitral valve opens earlier in ventricular diastole. When PHTN develops increased P2, pulmonary ejection sounds, murmurs of PI (Graham Steel), TR and right sided congestive heart failure (RVS3) can be heard. The diastolic murmur does not correlate with tee severity of MS but generally occurs throughout diastole in sever cases. Those in NSR (normal sinus rhythm) will have “presystolic accentuation” of the murmur due to atrial contraction.
Periphery
- Ankle/sacral edema (oedema) when there is right heart failure
- Left parasternal heave - presence of right ventricular hypertrophy due to pulmonary hypertension
- Tapping apex beat which is not displaced