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Valvular Heart Diseases 109

Another scenario when S1 becomes soft is when mitral
stenosis co-exists with dominant regurgitant lesions like
mitral or aortic regurgitation. In such a scenerio, the
clinical findings of the dominant regurgitant lesions (like
cardiomegaly with hyperdynamic apex) would usually
dominate the overall clinical picture.
14. When will you clinically suspect co-existing aortic
regurgitation in a patient with dominant mitral
stenosis?
As many as two-thirds of patients with dominant mitral
stenosis have co-existing aortic regurgitation. Even
severe co-existing aortic regurgitation is clinically silent
when accompanied by severe mitral stenosis. In the
presence of severe mitral stenosis, the widened pulse
pressure and peripheral signs of aortic regurgitation
may be absent. The clinical clue towards the presence
of co-existing aortic regurgitation in a patient with
dominant mitral stenosis is an early diastolic murmur
along the left sternal border. This murmur has to be
differentiated from the Graham-Steell’s murmur of
pulmonary regurgitation that can occur secondary to
pulmonary arterial hypertension in severe isolated mitral
stenosis. The clinical differentiation is made by dynamic
auscultation.
Maneuvers which increase the peripheral vascular
resistance like squatting, intensify the two murmurs
associated with aortic regurgitation (i.e. the decrescendo
early-diastolic murmur along the left sternal border and
the mid-diastolic Austin Flint murmur at the cardiac
apex). Maneuvers which decrease the peripheral
vascular resistance like exercise or amyl nitrate
inhalation diminishes both the murmurs associated
with aortic regurgitation. These maneuvers have exactly