Mitral stenosis clinical presentation

Auscultatory findings in Mitral stenosis
Audio of mid diastolic rumbling murmur of mitral stenosis
Discuss the differential diagnosis of Mitral stenosis

Discuss the differential diagnosis of AR (Aortic regurgitation)

Most important differential diagnosis of AR murmur are mitral stenosis and pulmonary regurgitation. Careful clinical examination of patients pulse, auscultation of cardiac murmur and dynamic auscultation will help to differentiate between them.

          The following charts will give you the major difference between aortic regurgitation and pulmonary regurgitation.

	Aortic regurgitation	Pulmonary regurgitation
Pulse	Collapsing pulse	Normal
Apex	Forceful	Normal
Features of PAH (Pulmonary artery hypertension)	Absent	Present
Murmur	Early diastolic murmur in 2nd aortic area that is conducted downward	EDM confined to pulmonary area

 Difference between AR with austinflint and mitral stenosis murmur

	AR with Austin flint murmur	Mitral stenosis
Pulse	Collapsing pulse	Low volume pulse
Atrial fibrillation	Less common	More common
Apex	Forceful apex with cardiomegaly	Tapping apex – no cardiomegaly
PAH	Uncommon	Common
S1 (First head sound)	Soft	Loud
Opening snap	Absent	Present

Audio of mid diastolic rumbling murmur of mitral stenosis.

Murmurs are produced due to abnormal turbulent blood flow across the heart valve.
The murmur of mitral stenosis is a  mid diastolic rough rumbling murmur heard at the apex of heart with the bell of stethoscope, patient lying down in the left lateral position, breath held in expiration.
The bellow video can here the typical sound of mid diastolic rumbling murmur of mitral stenosis.

Auscultatory findings in Mitral stenosis

Heart sounds in mitral stenosis

S1-The first heart sound is usually accentuated and it is slightly delayed in mitral stenosis.

S2-P2 the pulmonary component may be accentuated and A2 and P2 the two components of second heart sound are closely split.

Opening snap

Opening snap is an abnormal auscultatory finding in mitral stenosis. It usually follows the aortic component of second heart sound by 0.05–0.12 s. It is best heard at or just medial to apex of heart and most readily audible in expiration.

Significance of opening snap is that the time interval between the aortic component (A2) and the opening snap depend upon the severity of mitral stenosis. The time interval varies inversely with the severity of the MS. 

Murmur of mitral stenosis

The OS is followed by a diastolic murmur in mitral stenosis. It is a low-pitched, rumbling, diastolic murmur, which is heard  best at the apex with the patient in the left lateral recumbent position .

The murmur is accentuated by mild exercise (such as a few rapid sit-ups ) that is carried out just before auscultation. 

The duration of this diastolic murmur correlates with the severity of the mitral stenosis in patients with preserved cardiac output.

There is a presystolic accentuation of murmur in patients with sinus rhythm, the murmur often reappears or it becomes louder during atrial systole.

Sometimes a soft, grade I or II/VI systolic murmurs may be heard at the apex or along the left sternal border in pure MS and do not necessarily signify the presence of mitral regurgitation. 

Auscultatory findings in mitral stenosis due to associated lesions

If the patient develop severe pulmonary hypertension, a pansystolic murmur may be produced due to functional TR, this may be audible along the left sternal border and is louder during inspiration and diminishes during forced expiration. This phenomenon is called Carvallo’s sign.

When the cardiac output is markedly decreased in mitral stenosis, the typical auscultatory findings, including the diastolic rumbling murmur, may not be detectable. This is called silent MS, but they reappear if the cardiac output is restored.

The Graham Steell murmur of PR, is a high-pitched, diastolic, decrescendo blowing murmur heard along the left sternal border. This murmur occur due to dilatation of the pulmonary valve ring and is seen in patients with mitral valve disease and severe pulmonary hypertension.