Mime of Mitral Stenosis

Report:

Sinus rhythm

Left atrial abnormality

Possible right atrial abnormality

Right axis deviation +95o

Probable right ventricular hypertrophy (RVH)

RAD, Qrs V1

Nonspecific ST/T changes

Comment:

The patient had restrictive cardiomyopathy of unknown ætiology, with moderate mitral incompetence and large left atrium at catheter. She also had history of multiple pulmonary emboli. The trace is very suggestive of mitral stenosis, with impressive P mitrale and RAD. Given the decreasing prevalence of mitral stenosis, alternative diagnoses are becoming, statistically, more likely nowadays. Even in Pacific islanders. HOCM can look like this, too.

P wave in V2 is over 1.5 mm in height, indicating right atrial enlargement.

Sudden transition from LAA (manifest as massive PTF in V1 here) to tall peaked P wave in V2 is characteristic of right atrial enlargement, sometimes without any left atrial enlargement, especially in emphysema101. In this patient, however, there is a (known) certainty of left atrial enlargement; the V1-V2 combination probably represents biatrial enlargement.

I suggested mitral stenosis in my (blind) report. It pays not to say too much. John Morgan, Director of Cardiology at St. Vincent’s in Sydney, gave me two priceless pieces of advice: i. read Marriott and ii. always under-report!