Mixed mitral valve disease

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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3 Mixed mitral valve disease

Instruction

Listen to this patient’s heart.

Salient features

• The patient will have signs of both mitral stenosis and regurgitation.

• The candidate will be expected to indicate the dominant lesion (see below).

Proceed as follows:

• Look carefully for surgical scars of mitral valvotomy in all patients (scars under the left breast in female patients are often missed). Patients with previous valvotomy may have regurgitation and restenosis.

  Dominant mitral stenosis Dominant mitral regurgitation
Apex beat Tapping, not displaced Heaving and displaced
First heart sound Loud Soft
Third heart sound Absent Present

A third heart sound in mitral regurgitation indicates that any associated mitral stenosis is insignificant.

Note: There may be patients who do not have clear-cut signs such as a loud first heart sound with a displaced apex; in such cases you must say that it is difficult to ascertain clinically the dominant lesion and that cardiac catheterization should resolve the issue.

Diagnosis

This patient has mitral stenosis with mitral regurgitation (lesion), with the dominant lesion being stenosis caused by rheumatic heart disease (aetiology), and is in cardiac failure (functional status).

Questions

What is the cause of mitral stenosis with regurgitation?

Mixed mitral valve disease is usually caused by chronic rheumatic heart disease.

Which valves are most often affected by rheumatic heart?

The approximate frequencies are:

• mitral valve disease, 80%

• aortic valve, 50%

• combined mitral and aortic valve lesion, 20%

• tricuspid valve, 10%

• pulmonary valve, <1%.

What is the significance of a diastolic rumble in mitral regurgitation?

It signifies the presence of coexistent mitral stenosis. In the absence of mitral stenosis, it suggests that there is high diastolic transmitral flow and severe mitral regurgitation. Inhalation of amyl nitrate increases both the duration and intensity of the diastolic murmur caused by mitral stenosis, whereas it decreases them if the diastolic rumble is solely caused by mitral regurgitation. Also the presence of an opening snap suggests mitral stenosis as the cause of the diastolic rumble.

In patients with mitral regurgitation and a diastolic rumble, what does the presence of a giant left atrium indicate?

It indicates that there is no significant mitral stenosis.

What is the significance of multiple small calcified nodules on chest radiograph in this patient?

It indicates long-standing elevation of pulmonary venous pressure (Fig. 3.1).

image

Fig. 3.1 Mixed mitral valve disease, showing multiple small calcified nodules.

(With permission from Adam et al. 2008.)

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3 Mixed mitral valve disease

Instruction

Listen to this patient’s heart.

Salient features

• The patient will have signs of both mitral stenosis and regurgitation.

• The candidate will be expected to indicate the dominant lesion (see below).

Proceed as follows:

• Look carefully for surgical scars of mitral valvotomy in all patients (scars under the left breast in female patients are often missed). Patients with previous valvotomy may have regurgitation and restenosis.

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  Dominant mitral stenosis Dominant mitral regurgitation
Apex beat Tapping, not displaced Heaving and displaced
First heart sound Loud Soft
Third heart sound Absent