Physical Exam

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Physical Exam

• Patients have low cardiac output, pulmonary
  hypertension
• Systemic vasoconstriction may exhibit mitral
  facies.
• Patchy, pinkish-purple appearance of the cheeks
  resulting from dilated venules. Such subjects
  often manifest peripheral cyanosis associated
  with low cardiac output (why is there low CO?)
• It is commonly seen in mitral stenosis
  complicated by pulmonary hypertension.

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• Right ventricular failure and peripheral edema
• Jugular venous pulse usually exhibits a prominent
  A wave
• In patients with atrial fibrillation, the A wave
  and X descent disappear

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Heart Sounds

• A loud S1 is heard when the mitral valve is
  thickened and stenosed, but still pliable and
  flexible and is not heavily calcified.
• If the valve is particularly thick and calcified,
  there may be relatively little movement of the
  valve leaflets with opening or closing hence, S1
  (and the opening snap OS) may be soft. 

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• Second heart sound (S2)
• The pulmonic (P2) of the second heart sound is
  often increased in amplitude due to pulmonary
  hypertension
• Opening Snap (OS)
• The OS is one of the classic finding in cardiac
  physical diagnosis. It is due to a sudden tensing
  of the anterior MV leaflet. A loud OS indicates
  the diagnosis of mitral stenosis. A loud OS
  indicates as in a loud S1 that the valve is still
  pliable. A soft OS indicates the valve is
  indicate a restricted stiff valve.
• Best heard in the left parasternal region rather
  than at the apex

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Murmurs

• Diastolic rumbling murmur is low pitched, which
  is best heard over the cardiac apex with the bell
  of the stethoscope with the patient in the left
  lateral decubitus position (why?). The duration
  (not the intensity why?) of the murmur is a guide
  to the severity of the mitral narrowing

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Laboratory Examination

• ECG
• Insensitive technique for MS, but may show
  enlarged LA because of P-wave changes that appear
  broad or bifid
• If RVE is seen

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• Chest x-ray
• Left atrial enlargement with normal left
  ventricular size
• Occasionally calcification of the mitral valve
  that may show a c or j on the lateral view
• Changes in the lung fields are useful in
  estimating the height of pulmonary venous
  pressure

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Kerley B and A lines

• Kerley B lines Short, dense, horizontal lines
  most commonly seen in the costophrenic angles
  because of pulmonary edema
• Kerley A lines Straight, dense lines up to 4 cm
  in length running toward the hilum

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• Kerley B lines these findings are present in
  30 of patients with resting pulmonary artery
  wedge pressure below 20 mm Hg and in 70 with
  PCWP of gt20mm Hg

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• LA enlargement with prominent left atrial
  appendage

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Catheterization

• Is rarely necessary in the era of
  echocardiography
• Two circumstances in which catheterization is
  indicated
• The presence of a discrepancy between the
  patients symptoms suggesting severe MS and a
  non-invasive estimation (such as echo)
• Other problems such as concomitant CAD

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A simultaneous LV and PCWP demonstrates a MV
gradient throughout diastole
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Catheterization

• A prominent atrial contraction in the form of an
  elevated A wave and a gradual pressure decline
  after mitral valve opening (Y descent).
• The mean left atrial pressure is elevated about
  12 mm Hg.
• gt 20mm Hg is considered severe.

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Catheterization

• Left atrial size and thickening of mitral valve
  can be assessed through angiography and may
  outline thrombi
• Cardiac output can be determined by the Fick or
  dilution method

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Echo
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Treatment

• Patients with rheumatic heart disease should
  receive prophylaxis antibiotic therapy to prevent
  recurrence of rheumatic fever and against
  infective endocarditis
• Catheter balloon valvuloplasty can be performed
  or if necessary a commissurotomy or even a valve
  replacement

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