Page 114 - Clinical Pearls in Cardiology

102 Clinical Pearls in Cardiology

5. What are the clinical features of severe mitral
regurgitation?
The clinical signs indicating severe mitral regurgitation
are the following:
• Cardiomegaly (hyperdynamic apex) with apical
systolic thrill.
• Brisk carotid pulse called as the small water-hammer
pulse.
• Late systolic left lower sternal lift (due to the
regurgitant jet refluxing into the left atrium producing
an outward recoil of the anterior cardiac structures).
• Wide mobile split of S2.
• Left ventricular S3.
• Early-to-mid diastolic apical flow murmur.
The intensity of the systolic murmur is of limited
value in assessing the severity of the regurgitation.
However, most patients with severe mitral regurgitation
have a murmur of grade 3/6 or louder. When there is
severe cardiac failure, the systolic murmur of mitral
regurgitation may be inaudible (sometimes referred to
as silent MR).
6. When will you clinically suspect co-existing mitral
stenosis in a patient with dominant mitral regurgi-
tation?
Rheumatic mitral regurgitation is associated with some
degree of stenosis and fusion of the commissures in
about 90% of cases. Therefore, it is very common for the
mitral valve in rheumatic disease to be both regurgitant
and stenotic. When the mitral valve orifice is smaller
than 1.5 sq cm, then stenosis is predominant and it
determines the clinical presentation. When the mitral
valve orifice is larger than 2.0 sq cm, the regurgitation is
predominant and it determines the clinical presentation.