Ashwin Aby Thomas

PIMS

Cardiac Cycle

Mitral Stenosis is a Valvular Heart Disease charecterized by the narrowing of the orifice of mitral valve of the heart

Loud S1 Opening Snap Murmur Pre Systolic accentuation of the Murmur

The first heart sound S1 is unusually loud and may be palpable (tapping apex beat) because of increased force in closing the mitral valve. The first heart sound is made by the mitral and tricuspid heart valves closing. These are normally synchronous, and the sounds are termed M1 and T1 respectively. M1 becomes louder in mitral stenosis.

An opening snap which is a high pitched additional sound may be heard after the A2 (aortic) component of the second heart sound (S2) It correlates to the forceful opening of the mitral valve The mitral valve opens when the pressure in the left atrium is greater than the pressure in the left ventricle. This happens in ventricular diastole(after closure of the aortic valve), when the pressure in the ventricle precipitously drops

Phase of ventricular diastole

Isometric interval phase:
The isometric or isovolumetric interval is a relaxation phase and is the beginning of diastole During diastole, ventricular pressure is lower than that in the aorta. The aortic valve snaps shut. This produces the second heart sound. During this time, the ventricular pressure curve drops close to 0 mm Hg.

Rapid ventricular filling phase:

Ventricular pressure falls below atrial pressure. The Mitral valve opens and blood rushes rapidly from the atria into the ventricles. Almost 70% of the blood flows from the left atria to the left ventricle passively during this phase

Slow ventricular filling phase:

The slow ventricular filling phase is also known as diastasis or the last part of diastole. In this phase, a small amount of blood drains from the lungs into the atria and is added to the blood in the ventricles.

Atrial systole phase:

The atrial contraction or atrial kick during the last phase of ventricular diastole contributes 25% more blood to the ventricles During this phase the atrial contractions push the remaining blood in the left atria through the mitral valve into the left ventricle

A mid-diastolic rumbling murmur with presystolic accentuation will be heard after the opening snap. The murmur is best heard at the apical region. Since it is low-pitched it is heard best with the bell of the stethescope.Its duration increases with worsening disease. Rolling the patient towards left, as well as exercise will accentuate the murmur

Normal Heart Sound vs Mid Diastolic Murmur

During the phase of atrial systole,the atria actively pumps the blood through the stenosed mitral valve into the ventricle. The turbulent flow of blood through the stenosed mitral valve during this active phase accentuates the already existing mid diastolic murmur. In cases of Atrial fibrillation,the phase of Atrial Systole is affected and hence there is no active pumping of blood to the left ventricle via the stenosed mitral valve. Thus the pre systolic accentuation of the mid diastolic murmur is absent. Instead the blood passively flows during that period and causes the same rumbling murmur as was produced till then without any accentuation.

Pre systolic accentuation has also been observed in the presence of atrial fibrillation. Doppler echocardiography studies have showed that the presystolic accentuation is related to the antegrade flow of blood through a progressively narrowing mitral orifice during the end of ventricular diastole. The onset of mitral valve closure starts approximately 60ms before the valves close and produce S1

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