According to the statement of the patient,
she was reasonably well 10 days back.
Then she developed shortness of breath.
Initially it was increased with heavy
exertion and relieved by rest. This
shortness of breath increased day by day
and now even at rest. Patient wake up from
sleep 3 to 4 hours after going to bed.
She also feels discomfort on lying flat
and feels better in sitting position. The
shortness of breath was not associated
with episodic attack, cough, no diurnal
variation and not in allergic condition.
Also not associated with chest pain, fever
and hemoptysis. She also complaints of
palpitation which increased with exertion
and relieved by rest. This palpitation was
not associated with chest pain, syncopal
attack and increase frequency of
She complaints of general weakness on
mild to moderate daily activities. She
gave no history of weakness of any part
of the body.
For this above complaints patient got
admitted in this hospital for better
She gave no history of Rheumatic fever,
infective endocarditis or any other past
important contributory illness.
Patient previously one time
admitted in this hospital for same
complaints. But she cannot
mention the name of drugs. But
mention that drugs are associated
with increase frequency of
micturition and one drug she took
Her parents are alive. She has two
brothers, two sisters and one child.
All are alive and apparently healthy.
Decubitus: on choice
Body build: average
• Skin eruption:
• Body hair:
• Lymph node: not
• Thyroid gland: not
JVP: not raised
Pulse: 96 beats/
BP: 90/60 mm of
A. Cardiovascular system:
1. Arterial pulse:
a. Rate: 96 beats/ min
b. Rhythm: regular
c. Volume & character: normal
d. Symmetry: all peripheral pulses are
bilaterally symmetrically palpable.
e. Condition of the vessel wall: normal
f. Radio-femoral delay: absent
2. Blood pressure: 90/60 mm of Hg
3. JVP: Not raised
4. Examination of precordium:
Size and shape: normal
Visible pulsation: apex beat visible in mitral
area. Epigastric pulsation present
Venous engorgement: absent
No scar mark, No deformity.
Apex beat: left 5th
medially from mid clavicular line
and taping in nature
Left parasternal heave: present
Pulmonary component of second
heart sound: palpable.
heart sound: loud in mitral area
2ne heart sound: Pulmonary component of 2nd
sound is loud in pulmonary area
Murmur: there is a mid diastolic murmur in the mitral
area which is low pitch, localized, rough rumbling which is
best heard in left lateral position breath hold after
expiration with the bell of the stethoscope. Murmur grade
opening snap and presystolic
• Another pansystolic murmur is
present in tricuspid area which is
best heard in breath hold after
inspiration. Murmur grade is 3/6.
Shape of the chest: elliptical shaped
Movement of the chest: symmetrical
on both side
Subcostal recession: absent
Use of accessory muscle: absent
Scar mark: absent
Any visible pulsation : absent
Position of trachea: centrally placed
Position of apex beat: LT 5th
ICS 9 cm
lateral from midline
Chest expansion: symmetrical on both
Chest expansability: 3 cm
vocal femitus: equal on both sides
Percussion note:resonant on both side.
Mrs. Ruma, 20 years old female, married,
muslim, housewife hailing from Kahalu, Bogra
admitted in this hospital with the complaints of
shortness of breath for 10 days and palpitation
for same duration. Initially shortness of breath
was Newyork Heart Association (NYHA) class-
I. now it become NYHA class- IV. This
shortness of breath not associated with chest
pain, fever, cough, haemoptysis, episodic
attack, diurnal variation or allergic condition.
She also complaints of palpitation
which increased with exertion and
relieved by rest. Palpitation was not
associated with chest pain, syncopal
attack or increase frequency of
She complaints of fatigability in daily
activities and no weakness or paresis
in any parts of body.
On general examination:
appearance ill looking, anaemia,
cyanosis, oedema, jaundice,
clubbing, koilonychia, leukonychia
absent. Pulse- 96 beats/ min, blood
pressure- 90/60 mm of Hg,
respiration: 20 breaths/ min.
On systemic examination:
Pulse 96 beats/ min, BP- 90/60 mm of Hg,
JVP- not raised
Examination of precordium- size & shape of
the chest normal, apex beat is visible in
mitral area which is in left 5th
medially to midclavicular line and taping in
nature. Thrill- absent, left parasternal heave-
present, pulmonary component of 2nd
sound is palpable.
heart sound is loud in
mitral area and pulmonary component of
heart sound is loud in pulmonary area.
There is a mid diastolic murmur in mitral
area which is low pitch, localized, rough,
rumbling best heard in left lateral position in
breath hold after expiration with bell of the
stethoscope murmur grade is 3/6.
Opening snap and presystolic accentuation
Another pansystolic murmur is
present in tricuspid area which is best
heard in breath hold after inspiration.
Murmur grade is 3/6.
On respiratory system- bilateral basal
crepitation are present
Other systemic examination reveals
So my clinical diagnosis is-
Mitral stenosis and pulmonary hypertension
with tricuspid regurgitation with Pulmonary
oedema most probably rheumatic in origin.
1. ASD & TR ē Pulmonary HTN
2. Left atrial myxoma & TR ē Pul. HTN
3. Left atrial ball valve thrombus & TR
ē Pul. HTN
4. Severe AR & TR ē Pul. HTN
• Sinus tachycardia
• P mitralae
• Right ventricular hypertrophy
• Right axis deviation
2. CXR P/A view:
• Upper lobe diversion
• Straightening of the left heart border and
fullness of pulmonary conus
• Double shadow in right border of the heart
3. Echo- 2D:
• Thickening, fibrosis and calcification of
• Diastolic doming of Anterior Mitral Leaflet
• Both commissure are fused.
• LA seems to be dilated.
4. Echo- M mode:
• There is dilatation of left atrium (56mm)
• Reduced EF slope.
• Mitral valve area is 0.9 cm2
5. Echo- CD:
• Color flow mosaic passing from LA to
6. Cardiac catheterization: (Not done)
• It is unnecessary unless there is
a. Suspected coronary artery disease
b. Previous valvotomy
c. Signs of mitral regurgitation
d. Signs of severe pulmonary HTN
e. Signs of other valve disease
f. When mitral valve is calcified in chest
g. MV replacenment ( especially in elderly)
So final diagnosis is-
Mitral stenosis and pulmonary
hypertension with tricuspid
regurgitation with Pulmonary oedema
most probably rheumatic in origin.
Indication of PTMC
1. PTMC is best applied to symptomatic patients
with moderate to severe MS & favorable mitral
valve morphology that is Pliable non calcified
valve without significant sub valvular disease.
2. High surgical risk
3. Bridge procedure to mitral valve surgery
4. Patient refusal to surgery
5. Shortened life span with co morbidities.
Indication for Mitral valve
1. Associated substantial/significant mitral
2. Valve is rigid & calcified.
3. moderate to severe mitral Stenosis &
thrombus in the LA despite anti coagulant.
4. Severely distorted valve by previous operation.
5. If it is not possible to improve valve function
Common complication of MS
1. Pulmonary edema
2. Atrial tachy-arrhythmias
3. Thrombo-embolic complications .
4. Premature birth
5. Intra uterine growth restriction.
MANAGEMENT OF MS IN
Whole duration of pregnancy must be supervised by
Cardiologist & Gynaecologist.
If symptomatic – HF,AF
-Diuretics (with caution)
Termination of pregnancy-
If symptoms are not adequately controlled despite optimum
Trimester (13-28 wks)
-Optimal medical treatment
-Emergency PTMC / CMC – if symptoms are not well
controlled despite medical treatment.
Trimester (29-40 wks)
-Hospital delivery with shortening of 2nd
-Elective PTMC / CMC.
MANAGEMENT OF MS
At the beginning thoroughly examines the
Investigation according to necessity
Treatment according to severety
If tight MS: PTMC or operation before
If Moderate MS: Continue pregnancy and
follow up along with gynaecologist
If Mild Ms: Continue pregnancy without any