Mitral Stenosis with Severe Pulmonary Hypertension
Classic Murmur of Mitral Stenosis
Mid-diastolic low-pitched rumbling murmur of mitral stenosis with pre-systolic accentuation is best audible at the apex, in the left lateral position with the bell of the stethoscope.
Mitral Stenosis with Severe Pulmonary Hypertension
Non-valvular pulmonic ejection sound
Pulmonary artery dilatation due to severe pulmonary hypertension can cause a non-valvular pulmonic ejection sound which decreases with inspiration unlike any other right-sided event in the heart.
Pansystolic murmur of tricuspid regurgitation (TR) may be audible in severe MS with pulmonary hypertension and may be confused with associated mitral regurgitation.
The murmur of TR is better audible left parasternally in the 4th intercostal space, the intensity increases with inspiration and there will be an associated large v wave in the jugular venous pulse.
Graham Steell murmur – because of functional pulmonary regurgitation in severe pulmonary hypertension
High-pitched decrescendo diastolic murmur may (rarely) be audible along the left sternal border because of functional pulmonary regurgitation (Graham Steell murmur) in severe pulmonary hypertension, but more commonly this murmur indicates associated aortic regurgitation.
