Q. What are the Physical Signs of mitral stenosis?

A typical malar flush is described in mitral stenosis. It is difficult to appreciate in Indians. Pulse is normal or low volume. Atrial fibrillation is a common arrhythmia in patients with mitral stenosis. Presence of ventricular ectopics should raise a suspicion of digitalis toxicity. In a patient with pulmonary hypertension ‘a' wave may be prominent in jugular venous pulse. With increasing severity of tricuspid regurgitation ‘v' wave becomes prominent. With onset of atrial fibrillation ‘a' waves disappear. While left ventricular enlargement is absent, with severe pulmonary artery hypertension, right ventricle may form the apex. First heart sound is loud, but with a calcific and non pliable valve it may be muffled. Intensity of pulmonary closure sound depends upon the severity of pulmonary artery hypertension. A loud opening snap (OS) indicates a pliable valve.

Length of diastolic rumble at apex depends upon the severity of mitral stenosis. It may be mid diastolic or presystolic with mild mitral stenosis. Distance between aortic closure sound and opening snap indicates severity of mitral stenosis. Shorter A2-OS distance and longer murmur indicate severe mitral stenosis. Typically in patients with sinus rhythm mid diastolic murmur has presystolic accentuation. However, its presence in atrial fibrillation depends upon the cycle length. With severe pulmonary hypertension murmur of tricuspid regurgitation is present. Signs of right heart failure are often seen in patients with tight mitral stenosis and severe pulmonary hypertension.