• Secundum ASD with rheumatic MS.


  • More in females.


  • Effect of MS on ASD-
    • Increased left to right shunt
  • Effect of ASD on MS-
    • Decreased PVH due to shunting of blood from LA to RA.
  • Hemodynamics depends on –
    • Severity of MS
    • Size of ASD (usually it is large)
  • Severe MS-
    • PAH occurs in two ways
      • PVH leads to PAH
      • Increased left to right shunt leads to PAH
  • Mild to moderate MS-
    • Well tolerated due to shunting of LA blood.

Clinical features

  • Symptoms-
    • MS- orthopnoea, PND, hemoptysis
    • ASD- exertional dyspnoea, fatigue, palpitations
  • Signs of MS are less-
    • Loud S1 is still present
    • OS is rare
    • MDM is short
  • Signs of ASD are exaggerated-
    • ESM is loud and is associated with thrill
  • Other signs-
    • JVP is raised and has prominent a wave
    • Pulse is of low volume
    • Continuous high pitched murmur at LPSB if small ASD with severe MS


  • BAE
  • RVH is disproportionately prominent compared to size of ASD

Chest X-ray

  • RA, RV, PA and lung vascularity prominent
  • In spite of MS, PVH is absent


  • MVA is accurate as measure of MS. MVG is falsely low.


  • Closure of ASD (open or device) with correction of MS (BMV or OMV)