Clinical Assessment Mild to moderate chronic RHD is almost always asymptomatic in children and young adults Even severe RHD may be associated with minimal or no symptoms in the young Without surgical intervention for this latter group of patients, a rapid decompensatory phase often follows.30 Mitral Regurgitation In the setting of MR, symptoms occur as increasing left atrial pressure causes pulmonary venous hypertension with symptoms of breathlessness In the setting of chronic severe MV disease, symptoms may be very gradual and very subtle, such as being unable to complete a full game of football—thus shortness of breath during peak physical activity This may progress to shortness of breath at rest, followed in time by clinical decompensation and death More rapid progression of symptoms can also occur in the setting of acute-on-chronic MV disease The clinical signs of MR include a pansystolic murmur heard best at the apex with radiation to the axilla, as the direction of regurgitant jet is usually posterolateral Less commonly the murmur radiates medially if the regurgitant jet is directed that way Patients with moderate or more severe MR will have lateral displacement of the apex beat, and there may be an associated diastolic murmur related to increased transmitral flow If MR is severe, ECG and chest x-radiograph (CXR) will demonstrate left ventricular (LV) dilatation/hypertrophy as well as pulmonary congestion Mitral Stenosis In the setting of MV stenosis, progressive obstruction to LV inflow develops, leading to a diastolic gradient between the left atrium and ventricle This pressure gradient is increased in settings of increased flow and faster heart rates, for example during exercise, pregnancy, or in the presence of atrial fibrillation with rapid ventricular rates Patients usually do not develop symptoms until the MV orifice decreases to less than 2 cm2 The initial symptom is exertional dyspnea with symptoms of orthopnea and paroxysmal dyspnea as the MV orifice decreases to less than 1.0 to 1.5 cm2.31,32 Symptoms of cough, hemoptysis, chest pain, palpitations, hoarse voice due to compression of the left recurrent laryngeal nerve and left atrial dilatation are signs of very advanced disease.33 The characteristic clinical finding of mild to moderate MS is a low-pitched, diastolic rumble or heart murmur heard best at the apex with the patient in a left lateral position The murmur is accentuated by increasing heart rate with mild exercise As disease progresses in severity, the pulses become small in volume and a parasternal heave and loud P2 develop due to pulmonary hypertension Unless the patient is in atrial fibrillation (AF), the duration of the murmur increases and a presystolic accentuation develops Less commonly, patients may present with or have signs of systemic embolism from the left atrium, although this is likely related more to the development of AF rather than the severity of the MS in itself.34 ECG is useful to confirm sinus rhythm or AF Left atrial enlargement and right ventricular hypertrophy is a marker of severe disease CXR may show left atrial enlargement and upper lobe diversion of blood flow Calcification of the MV apparatus may be visible, as well as pulmonary congestion if in heart failure Aortic Regurgitation Patients with chronic stable moderate or severe regurgitation often remain asymptomatic for years Eventually dyspnea on exertion, orthopnea, and even paroxysmal nocturnal dyspnea and edema develop Angina can occur, even if the patient has normal coronary arteries, as the result of reduced coronary perfusion due to low diastolic blood pressure The clinical signs of mild AR are normal pulses and an early diastolic, blowing decrescendo diastolic murmur best heard at the lower left sternal edge at the end of expiration with the patient sitting upright and leaning forward In general, more severe disease is associated with a shorter murmur A widened pulse pressure indicates moderate to severe AR Collapsing pulses indicate severe AR In torrential AR, the murmur is heard with the patient lying flat and is associated with what is described as a “water-hammer pulse.” The Korotkoff sounds are heard almost down to the pressure of zero The apical impulse is hyperdynamic and displaced due to LV enlargement The presence of a systolic flow murmur across the AV reflects increased stroke volume If AR is severe, the ECG will show increased LV voltages and the CXR will demonstrate left ventricle enlargement Aortic Stenosis Mild to moderate aortic stenosis is often asymptomatic and is associated with an ejection systolic murmur at the right upper sternal edge With severe aortic stenosis, a classic triad of symptoms may develop: dyspnea on exertion, angina, and syncope On auscultation, a loud, low-pitched midsystolic ejection murmur in the aortic area will be noted, radiating to the neck and often associated with a thrill over the aortic area and at the suprasternal notch In the setting of severe aortic stenosis, an ECG will show LV hypertrophy The CXR often remains normal in isolated aortic stenosis Tricuspid Regurgitation Symptoms of tricuspid regurgitation are often more related to the severity of coexisting MV disease Specific features due to tricuspid regurgitation include abdominal discomfort due to hepatomegaly, ascites, weight loss, and jaundice If tricuspid regurgitation is severe on clinical assessment, jugular venous pressure will be elevated A pansystolic, low-pitched cardiac murmur will be heard, loudest at the left lower sternal edge, that increases in intensity with inspiration If tricuspid regurgitation is secondary to pulmonary hypertension, the murmur tends to be higher-pitched with a loud second heart sound.33