Lutembacher's syndrome physical examination

The physical findings in an adult with Lutembacher’s syndrome depends on:

• Size of the atrial septal defect
• Degree of left-to-right shunt
• Pressure in pulmonary vasculature
• Severity of the mitral stenosis
• Distensibility of the right ventricle
• Other associated anomalies such as tricuspid regurgitation, aortic stenosis

• Precordial bulge: The left-to-right shunting of blood causes right atrial enlargement that can present as a precordial bulge. The precordial bulge can cause a counter development of Harrison’s groove that are horizontal depressions along the sixth and seventh costal cartilages at the lower margin of the thorax where the diaphragm attaches to the ribs.

• Precordial lift: An increased left-to-right atrial shunt can cause a hyperdynamic right ventricular flow that can be seen as precordial lift on inspection.

• Right ventricular impulse: An increased left-to-right atrial shunt can cause a hyperdynamic right ventricular impulse or heave. The heave can be best palpated at the left sternal border or the subxiphoid area.

• Pulmonary artery pulsations: Pulsatile, enlarged pulmonary artery pulsation can be felt at the second left intercostal space. These are more pronounced in patients with large left-to-right shunts. Patients with obstruction to right ventricular outflow have a less dynamic right ventricular impulse and may present with more of a tapping or thrusting quality.

• The classic presentation of pure mitral stenosis such as the loud first heart sound, opening snap, mid-diastolic rumble with presystolic accentuation are not usually heard.^[1]
• A continuous murmur may be present in some cases of Lutembacher’s syndrome with small ASD and a tight mitral stenosis because of the high left atrium-to-low right atrial pressure difference across the ASD, which persists during the entire cardiac cycle.^[1]

• A loud pulmonic mid-systollic murmur and a holosystollic murmur due to the presence of a tricuspid regurgitation may also be present in these patients.^[1]

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