MioAtlas
Comparison

Rheumatic mitral stenosis vs Degenerative mitral regurgitation (flail P2): clinical and ECG differences

Side-by-side comparison of Rheumatic mitral stenosis and Degenerative mitral regurgitation (flail P2) according to the MioAtlas 3D cardiac simulator model.

Rheumatic mitral stenosis
View full clinical guide Open in 3D simulator
Degenerative mitral regurgitation (flail P2)
View full clinical guide Open in 3D simulator

Findings by layer and diagnostic parameters

Layer / Finding Rheumatic mitral stenosis Degenerative mitral regurgitation (flail P2)
Hemodynamics
  • Mean transmitral gradient: L < 5 mmHg, M 5–10 mmHg, G > 10 mmHg (according to plan G1-01; in current V1/V2 guidelines interpreted conditional on HR) [G1-01] [V1].
  • Left atrial pressure (mean pulmonary capillary wedge pressure / retrograde mean right atrial pressure): Elevated proportionally to stenosis severity and heart rate [G1-01] [V1].
  • Pulmonary artery systolic pressure: Elevated in moderate and severe stages (> 30–50 mmHg) [V1] [G1-01].
  • Left ventricular volume overload with progressive increase in end-diastolic and end-systolic volumes, with initially hyperdynamic ejection fraction (> 65 %) declining as myocardial contractility fails [V1] [G1-05].
  • Left atrial pressure: Elevated in severe stages, with prominent 'v' wave [V1] [V3].
Rhythm
  • Initial rhythm: Normal sinus rhythm in early stages [V1].
  • In advanced stages: Frequent atrial fibrillation due to dilation and fibrotic remodeling of the left atrium [V1] [G1-04].
  • Normal sinus rhythm in initial stages [V1].
  • Atrial fibrillation frequent in advanced chronic stages due to progressive dilation of the mitral annulus and left atrium [V1] [G1-05].
ECG
  • Left atrial enlargement (left atrial enlargement, broad notched P mitrale in lead II > 0.12 s and prominent negative component in V1 > 0.04 s·mm) in sinus rhythm [E1].
  • Right ventricular hypertrophy or strain (right ventricular hypertrophy, tall R wave in V1, right axis deviation) in stages with moderate to severe pulmonary hypertension [E1].
  • Left atrial enlargement (left atrial enlargement, P mitrale) in sinus rhythm [E1].
  • Left ventricular hypertrophy due to volume overload (left ventricular hypertrophy voltage criteria, prominent R waves in lateral leads) [E1].
Heart sounds and murmurs
  • First heart sound (S1): Loud, snappy, and tapping (loud S1) in mild/moderate forms due to vigorous closure of pliable leaflets; softens in very advanced stages if the valve is heavily calcified [G1-01] [G1-10].
  • Opening Snap (OS): High-pitched, sharp early diastolic sound following the second heart sound (A2). The A2-OS interval is inversely proportional to severity (the higher the left atrial pressure, the earlier the mitral valve opens: interval < 60–80 ms in severe stenosis vs > 100 ms in mild stenosis) [G1-01] [G1-15].
  • Diastolic rumble: Low-pitched, rolling mid-diastolic murmur (rumble) auscultated with stethoscope bell at the apex in the left lateral decubitus position [G1-01] [G1-15].
  • Presystolic accentuation: Late systolic / presystolic crescendo increase of rumble intensity due to active atrial contraction. Present only in sinus rhythm; completely absent once atrial fibrillation supervenes [G1-01] [G1-15].
  • Second heart sound (S2): Accentuated pulmonary component (P2) in the presence of pulmonary hypertension [G1-11].
  • Holosystolic murmur: High-frequency regurgitant murmur beginning immediately with S1 and encompassing or extending beyond the second heart sound (S2) [V3] [G1-14].
Murmur radiation depending on flail leaflet:
  • In chordal rupture of the posterior leaflet (most frequent): Regurgitant jet is directed eccentrically anteromedially toward the interatrial septum and aortic root, so the murmur radiates toward the cardiac base, aortic area, and carotids [V3] [G1-06] [G1-14].
  • In anterior leaflet involvement: Jet is directed toward the posterior left atrial wall and radiates classically to the left axilla and back [V3] [G1-06] [G1-14].
  • First heart sound (S1): Decreased or obscured by the early onset of the murmur [G1-10].
  • Third heart sound (S3): Frequent at the apex due to increased rapid ventricular diastolic filling [G1-12] [V1].
Arterial pulse
  • Normal amplitude in mild stages; small volume pulse (pulsus parvus) in severe forms with restricted forward output [B4].
  • Brisk, sharp pulse with rapid collapse (pulsus celer et brevis) due to rapid stroke volume ejection into two low-resistance runoff pathways (aorta and left atrium) [B4].
Jugular venous pulse
  • Prominent 'a' wave in sinus rhythm if pulmonary hypertension is present; prominent 'v' wave and loss of 'a' wave if atrial fibrillation or secondary tricuspid regurgitation supervenes [B3] [G1-04].
  • Normal when compensated; elevation of 'v' wave if pulmonary hypertension and secondary tricuspid regurgitation supervene [B3].
Maneuvers
  • Left lateral decubitus position with mild exercise (squatting / handgrip): Increases venous return and heart rate, magnifying the transmitral gradient and the intensity of the diastolic rumble [G1-15] [V1].
  • Valsalva maneuver (strain phase): Decreases venous return and softens the rumble [G1-15].
  • Inspiration: Does not increase the mitral rumble (distinguishing it from tricuspid rumble) [G1-15].
  • Isometric handgrip: Markedly increases holosystolic murmur intensity by raising aortic afterload and LV-LA transmural gradient [B1].
  • Valsalva maneuver (strain phase): Decreases murmur intensity by reducing preload [B1].
  • Squatting: Increases holosystolic murmur intensity [B1].

Sources and bibliographic references

Rheumatic mitral stenosis

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  4. [G1-01] Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice . J Am Soc Echocardiogr (2009) . DOI: 10.1016/j.echo.2008.11.029 PubMed: 19130998
  5. [G1-04] Acute rheumatic fever and rheumatic heart disease . Nat Rev Dis Primers (2016) . DOI: 10.1038/nrdp.2015.84 PubMed: 27188830
  6. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  7. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  8. [G1-15] Diastolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250187
  9. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  10. [V2] 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2021) . DOI: 10.1161/CIR.0000000000000923 PubMed: 33332150

Degenerative mitral regurgitation (flail P2)

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [G1-05] Clinical outcome of mitral regurgitation due to flail leaflet . N Engl J Med (1996) . DOI: 10.1056/NEJM199611073351902 PubMed: 8875918
  6. [G1-06] The mitral apparatus. Functional anatomy of mitral regurgitation . Circulation (1972) . DOI: 10.1161/01.cir.46.2.227 PubMed: 5046018
  7. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  8. [G1-12] The Third Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250184
  9. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  10. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  11. [V2] 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2021) . DOI: 10.1161/CIR.0000000000000923 PubMed: 33332150
  12. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623