Page 120 - Clinical Pearls in Cardiology

108 Clinical Pearls in Cardiology

• Right ventricular apex (due to major right ventricular
enlargement in severe pulmonary arterial hyper-
tension).
• Long diastolic murmur in the apical area with narrow
A2–opening snap (OS) interval (severity is directly
proportional to duration of murmur and inversely
proportional to A2–OS interval).
• Diastolic thrill in the apical area.
• Left parasternal heave due to right ventricular
hypertrophy.
• Peripheral edema due to right ventricular failure.
Any maneuver that can increase the heart rate (e.g.
mild exercise like few sit-ups) will enhance the audibility
of the diastolic rumbling murmur. The murmur of mitral
stenosis may be inaudible in very low blood flow states
like ‘tight’ mitral stenosis with severe pulmonary arterial
hypertension (sometimes referred to as silent MS).
13. What are the causes for soft S1 and absent opening
snap in a case of mitral stenosis?
There are two important causes for soft S1 and absent
opening snap in a person with mitral stenosis. They are
the following:
• Calcification of the mitral valve leaflets: Calcification
of the mitral valve is an important finding in mitral
stenosis because it determines whether the treatment
option will be balloon valvuloplasty or valve
replacement (valve replacement should be done for
severely calcified mitral valve).
• Low blood flow states like severe pulmonary arterial
hypertension.
• Posterolateral displacement of the left ventricle due
to gross dilatation of the right ventricle in severe
pulmonary arterial hypertension.