A 25 years old female presented with dyspnea with diastolic rumble on examination

A 25 years old female presented in cardiology clinic with DOE for last 6 months, now worsened cough to affect her daily activities, she also complained of intermittent palpitations. On examination her BP was 100/60mmHg with regular pulse of 90bpm, pedal edema and giant ‘a’ wave on JVP. Auscultation revealed soft S1 and mid-diastolic rumble at apex and sternal end. Murmur accentuated on expiration as well as on leg raising and squatting. Lungs were clear. ECG showed bi-atrial enlargement
a)      What is diagnosis?
b)      What is the reason for soft S1 and giant ‘a’ wave in JVP
c)      Why diastolic murmur accentuated on leg raising and squatting
d)      What are some of the limitations of calculating PH based on TR jet


a. MS and TS
b. Soft S1 is due to severely calcified valve and giant ‘a’ wave is due to TS
c. Increased venous return and flow through stenotic tricuspid valve
d. Poor jet alignment, poor window unable to visualize TR, RV failure, Chamber equalization


1. Braunwald Heart Disease – A Textbook of Cardiovascular Medicine 10th edition - Chapter 17 – Page 297- TV disease, PV disease and drug induced valve disease (Rivero – carvallo sign)
2. ASE Guidelines for assessment of valvular disease 2009