3 Mixed mitral valve disease
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).
• 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.
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