Listen to this patient's heart.


· 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.
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.


This patient has mitral stenosis with mitral regurgitation (lesion), with the dominant lesion being stenosis
due to rheumatic heart disease (aetiology), and is in cardiac failure (functional status).
Read these papers for further information: Circulation 1973; 48: 357; Ann Intern Med 1972: 77: 939.


What is the cause of mitral stenosis with regurgitation?
Mixed mitral valve disease is usually caused by chronic rheumatic heart disease.
What are the approximate frequencies with which various valves are affected by rheumatic heart
· Mitral valve disease ~(1%
· 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 regur-gitation. Inhalation of amyl nitrate increases
both the duration and intensity of the diastolic murmur due to mitral stenosis whereas it decreases them if
the diastolic rumble is caused solely 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.
Joseph K. Perloff is contemporary Professor of Cardiology, Los Angeles; his chief interest is congenital
heart disease.
William C. Roberts is a contemporaryUS cardiac pathologist and Editor of the American Journal of