Figure 200l

Base and apex phonocardiograms are recorded simultaneously with the mitral valve echocardiogram in three patients with chronic rheumatic mitral valvular disease. In the left panel, a soft opening snap is coincident with the maximal opening of a thickened, relatively immobile, stenotic mitral valve. In the center panel, calcified fixation of the severely stenotic mitral valve is present, and an opening snap is absent. Note that the onset of the diastolic rumble begins after the maximal anterior excursion of the heavily calcified valve. In the right panel, an opening snap occurs at the maximal opening of the nonstenotic rheumatic valve A holosystolic murmur of mitral regurgitation is present and no gradient was found across of the mitral valve at cardiac catheterization. A loud S1 gallop follows the opening snap and occurs during the early E-F slope of the rheumatic mitral valve