The Power Course

Clinical Features of Mitral stenosis are all except


1 ) Loud first heart sound
2 ) S3 is heard
3 ) Presystolic accentuation of a mid-diastolic murmur may absent in presence of atrial fibrillation
4 ) A2 to opening snap gap varies inversely with the severity of mitral stenosis


In mitral stenosis, there is obstruction of blood flow from the left atrium to the left ventricle. The third heart sound is from the rapid filling of the ventricle read about the cardiac cycle.

 In the presence of an obstruction to flow S3 is usually absent. The presence of S3 in this clinical scenario suggests mitral regurgitation instead.

A2 component of Second heart sound and opening snap is inversely related to the severity of mitral stenosis. This means a longer gap between the opening snap and A2 component less severe the mitral stenosis.

Presystolic accentuation is due to atrial systole, in presence of atrial fibrillation, there is no effective atrial systole thus the absence of presystolic accentuation of mid-diastolic murmur.

Loud first heart sound is, because of high left atrial pressure, the left ventricle needs to reach a higher pressure before it can close the mitral valve and hence LV pressure has more time to accelerate and the wide closing excursion of the leaflets.


S3 is heard

Further Reading

Mitral Stenosis

The most common cause of mitral stenosis is Rheumatic heart disease (RHD) in India. The mitral valve has two leaflets anterior and posterior leaflets. in RHD there is a fusion of commissure between anterior and posterior leaflets. This leads to the decreased opening of the mitral valve during ventricular diastole. Left atrium gets dilated due to increased backpressure further this increased left atrial pressure is transmitted to pulmonary veins leading to pulmonary venous congestion and pulmonary artery hypertension leading dilatation of right ventricle and right atrium. 

In mitral stenosis left ventricle spared from pressure changes so in pure mitral stenosis (i.e not associated with any other valvular lesions) there is left heart failure but not left ventricular failure

Due to high pressure in the left atrium these patients are prone to develop atrial fibrillation.


Diuretics, preferably loop diuretics are given to relieve pulmonary congestion.

Lanoxin tablets are given to reduce the ventricular rate in the presence of atrial fibrillation, even beta-blockers can also be used. Avoid verapamil and diltiazem in the presence of heart failure

PTMC (percutaneous transmitral commissurotomy) is an intervention done to open then fused mitral leaflet with help of inflating the balloon at the mitral valve.

Last Modified : 25-Dec-2019

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