The findings at the bedside in all cases of mitral regurgitation are not the same and, specifically, the chronicity of the lesion makes a major impact on the bedside findings. In our case, we had chronic mitral regurgitation. What does that mean? It means over time that left atrium keeps expanding as mitral regurgitation keeps begetting more mitral regurgitation, and then it becomes like a cellophane baggie – not a tight tennis ball that you’d find if it were acute mitral regurgitation. No this is a very giving left atrium, therefore, it acts as a buffer, and what does that do? You don’t reflect pressures that are high back into the pulmonary circulation, and what does all that mean at the bedside? Well, number one, you look at the veins, you wouldn’t find a high central venous pressure in the chronic case in most cases that you would see. You wouldn’t have a giant “a” wave. You wouldn’t have a right ventricular impulse of the classic type. In addition, when you listen, you wouldn’t have a loud pulmonary second sound reflecting pulmonary hypertension, and when you listen at the apex to the mitral regurgitation murmur, it goes throughout all of systole, because that left atrium will take the blood during all of systole… and you know? That left atrium is so baggy and its contractility diminished enough, it doesn’t have the oomph to generate an S4.

Remember, the chronicity or acute nature of the lesion has a major impact on the bedside findings.