When is mitral stenosis heard

The 2 nd hear sound, S2 dub , marks the end of systole beginning of diastole. Related to the closure of the aortic and pulmonic valves. Loudest at the base. You can relate the auscultatory findings to the cardiac cycle by simultaneously palpating the carotid artery while listening to the heart: S1 S2 Just precedes carotid pulse Follows carotid pulse Louder at apex Louder at base Lower pitch and longer than S 2 Higher pitch and shorter than S 2 Because systole is shorter than diastole: First of two grouped beats Second of 2 grouped beats If anything abnormal is found, move the stethoscope around until the abnormality is heard most clearly.

Analyze each category individually and then put it together to diagnosis the problem Category Definition Audio examples Aortic stenosis: Murmur: Harsh late-peaking crescendo-decrescendo systolic murmur Heard best- left 2nd ICS Radiation to the carotids.

Possible associated findings: Abnormal carotid pulse Diminished and delayed "pulsus parvus and tardus" Sustained Apical impulse Calcified aortic valve on CXR Mitral Regurgitation: Murmur: Blowing holosystolic murmur Heard best at the apex Radiation to the axilla and inferior edge of left scapula.

Neck Veins. You can relate the auscultatory findings to the cardiac cycle by simultaneously palpating the carotid artery while listening to the heart: S1 S2 Just precedes carotid pulse. Possible associated findings: Abnormal carotid pulse Diminished and delayed "pulsus parvus and tardus" Sustained Apical impulse Calcified aortic valve on CXR. This allows blood to flow freely into the right ventricle and left ventricle from the atria. The aortic and pulmonary valves are shut, which prevents an abnormal backflow of blood into the ventricles from the aorta and pulmonary artery.

Ventricular systole occurs as the ventricles contract, increasing the pressure within the ventricles. The increased pressure causes the closure of the mitral and tricuspid valves, this prevents regurgitation of blood from the ventricles into the atria.

At this point, the volume of blood within the ventricles remains constant as the aortic and pulmonary valves have not yet opened. This phase of ventricular systole is called isovolumetric contraction. Eventually, the pressure within the ventricles exceeds the pressure in the pulmonary artery and aorta causing the pulmonary and aortic valves to open. Blood is ejected from the ventricles during ventricular ejection phase. The ventricles then begin to relax following contraction ventricular diastole.

The drop in pressure within the ventricle causes the aortic and pulmonary valves to close, to prevent backflow regurgitation of blood into the ventricles.

For more information, see the Geeky Medics guide to the electrical conduction system of the heart. The first heart sound S1 is caused by the closure of the mitral and tricuspid valves. It marks the start of ventricular systole, and a peripheral pulse is felt at the same time or shortly after S1. The second heart sound S2 is caused by the closure of aortic and pulmonary valves. It marks the end of ventricular systole, and the start of diastole. The pulmonary valve may close just after the aortic valve.

Closure of the pulmonary valve just after the aortic valve is prolonged during inspiration, or in defects which cause more blood to be pumped out of the right ventricle. Therefore, S2 may not always be heard as one discrete sound but may be muffled or have two discrete sounds split S2. It is important to have a structured approach to interpreting heart murmurs. See the Geeky Medics guide to cardiovascular examination for more information on how to perform auscultation.

Table 1. The Levine scale for grading cardiac murmurs according to intensity. A thrill is a palpable vibration caused by turbulent blood flow through a heart valve. Thrills may be felt when palpating the anterior chest wall during a cardiovascular examination. Aortic stenosis AS refers to a tightening of the aortic valve at the origin of the aorta. Aortic stenosis is associated with an ejection systolic murmur heard loudest over the aortic valve.

The murmur of aortic stenosis commonly radiates to the carotid arteries. For more information, see the Geeky Medics guide to aortic stenosis examination. Mitral regurgitation MR occurs when there is backflow regurgitation of blood from the left ventricle into the left atria through the mitral valve during ventricular systole. Mitral regurgitation is associated with a pansystolic murmur heart loudest over the mitral area and radiating to the axilla. Aortic regurgitation AR occurs when there is backflow of blood from the aorta into the left ventricle during ventricular diastole.

Aortic regurgitation is associated with an early diastolic murmur heard loudest at the left sternal edge. Aortic regurgitation can be either acute or chronic. Chronic AR is often asymptomatic. The pulmonic component of S2 P2 is responsible for the impulse and results from pulmonary hypertension. An RV impulse heave palpable at the left sternal border may accompany jugular venous distention when pulmonary hypertension is present and RV diastolic dysfunction develops.

Auscultatory findings in mitral stenosis include a loud S1 caused by the leaflets of a stenotic mitral valve closing abruptly M1 ; it is heard best at the apex.

S1 may be absent when the valve is heavily calcified and immobile. A normally split S2 with an exaggerated P2 due to pulmonary hypertension is also heard see table Distinguishing the Murmurs of Tricuspid Stenosis and Mitral Stenosis Distinguishing the Murmurs of Tricuspid Stenosis and Mitral Stenosis Mitral stenosis is narrowing of the mitral orifice that impedes blood flow from the left atrium to the left ventricle.

Common complications Most prominent is an early diastolic opening snap as the leaflets billow into the LV, which is loudest close to left lower sternal border; it is followed by a low-pitched decrescendo-crescendo rumbling diastolic murmur, heard best with the bell of the stethoscope at the apex or over the palpable apex beat at end-expiration when the patient is in the left lateral decubitus position.

The opening snap may be soft or absent if the mitral valve is calcified; the snap moves closer to S2 increasing duration of the murmur as mitral stenosis becomes more severe and LA pressure increases. The diastolic murmur increases after a Valsalva maneuver when blood pours into the LA , after exercise, and in response to maneuvers that increase afterload eg, squatting, isometric handgrip.

The murmur may be softer or absent when an enlarged RV displaces the LV posteriorly and when other disorders pulmonary hypertension, right-sided valve abnormalities, AF with fast ventricular rate decrease blood flow across the mitral valve. The presystolic crescendo is caused by increased flow with atrial contraction. However, the closing mitral valve leaflets during LV contraction may also contribute to this finding but only at the end of short diastoles when LA pressure is still high.

Early diastolic murmur of coexisting aortic regurgitation Aortic Regurgitation Aortic regurgitation AR is incompetency of the aortic valve causing backflow from the aorta into the left ventricle during diastole. Causes include valvular degeneration and aortic root dilation Graham Steell murmur a soft decrescendo diastolic murmur heard best along the left sternal border and caused by pulmonic regurgitation Pulmonic Regurgitation Pulmonic pulmonary regurgitation PR is incompetency of the pulmonic valve causing blood flow from the pulmonary artery into the right ventricle during diastole.

Diagnosis of mitral stenosis is suspected clinically and confirmed by echocardiography Echocardiography This photo shows a patient having echocardiography. This image shows all 4 cardiac chambers and the tricupsid and mitral valves. Echocardiography uses ultrasound waves to produce an image of Typically, 2-dimensional echocardiography shows abnormal valve and subvalvular structures. It also provides information about the degree of valvular calcification and stenosis and LA size.

Doppler echocardiography provides information about the transvalvular gradient and pulmonary artery pressure. The normal area of the mitral valve orifice is 4 to 5 cm 2. However, the relationship between the area of the valve orifice and symptoms is not always consistent.

Color Doppler echocardiography detects associated MR. Transesophageal echocardiography can be used to detect or exclude small LA thrombi, especially those in the LA appendage, which usually cannot be seen transthoracically. Transesophageal echocardiography also can better assess mitral regurgitation when mitral calcification causes acoustic shadowing of the left atrium.

Two-dimensional echocardiogram, close-up parasternal long-axis view. Video demonstrates limited excursion of the mitral valve leaflets during systole. Chest x-ray Chest x-ray Chest imaging includes use of plain x-rays, computed tomography CT scanning, magnetic resonance imaging MRI , nuclear scanning, including positron emission tomography PET scanning, and With barium in the esophagus, the lateral chest x-ray will show the dilated LA displacing the esophagus posteriorly.

The upper lobe pulmonary veins may be dilated. A double shadow of an enlarged LA may be seen along the right cardiac border. Horizontal lines in the lower posterior lung fields Kerley B lines indicate interstitial edema associated with high LA pressure. Exercise testing Stress Testing In stress testing, the heart is monitored by electrocardiography ECG and often imaging studies during an induced episode of increased cardiac demand so that ischemic areas potentially at risk Further information can be obtained from stress echocardiography evaluation of changes in valve gradient and pulmonary pressure.

Cardiac catheterization Cardiac Catheterization Cardiac catheterization is the passage of a catheter through peripheral arteries or veins into cardiac chambers, the pulmonary artery, and coronary arteries and veins. Cardiac catheterization The natural history of mitral stenosis varies, but the interval between onset of symptoms and severe disability is about 7 to 9 years. Symptomatic results of balloon or surgical commissurotomy are equivalent in patients with valves that are not calcified.

However, after a variable period of time, function deteriorates in most patients due to restenosis, and valve replacement may become necessary.

Risk factors for death are atrial fibrillation Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Cause of death is most commonly heart failure or pulmonary or cerebrovascular embolism.

Asymptomatic patients with mitral stenosis require no treatment other than appropriate prophylaxis against rheumatic fever Antibiotic prophylaxis Rheumatic fever is a nonsuppurative, acute inflammatory complication of group A streptococcal pharyngeal infection, causing combinations of arthritis, carditis, subcutaneous nodules, erythema Surveillance with serial TTE is important, because RV enlargement and rise in RV systolic pressure can occur without patients noticing a change in functional state, and without a decrease in mitral valve area.

Early intervention may relieve pulmonary hypertension before it becomes permanent. Mildly symptomatic patients usually respond to diuretics and, if sinus tachycardia or AF is present, to beta-blockers or calcium channel blockers, which can control ventricular rate. Anticoagulation with a vitamin K antagonist not a direct-acting oral anticoagulant [DOAC] is indicated to prevent thromboembolism if patients have or have had AF, embolism, or a left atrial clot.

Extended restoration of sinus rhythm is rarely possible. All patients should be encouraged to continue at least low levels of physical exercise despite exertional dyspnea.