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Peripheral cyanosis and a small volume pulse may be present and are due to vasoconstriction. The apical impulse is often ‘tapping’ in quality, and a right ventricular thrust may be felt behind and to the left of the lower sternum and in the epigastria. A diastolic thrill is often palpable at the apex. A diastolic murmur maximal at or confined to the region of the apex beat is the hallmark of mitral stenosis. The murmur may be pre-systolic in time or fill most of diastole with apparent pre-systolic accentuation. It is usually low-pitched and rumbling in quality and best heard with a bell stethoscope and the patient lying on the left side. In early cases it may only be heart if the heart rate is increased, e.g. by exercise. The pre-systolic part of the murmur is dependent on trail systole, and hence disappears with the onset of atrial fibrillation. The first heart sound at the apex is characteristically loud and sudden. An added sound may be accentuated from pulmonary hypertension. An added sound may frequently be heard immediately preceding the mid-diastolic murmur. Enlargement of the left the opening of the readily be seen on radiological examination, especially in the right oblique position, in barium – filled oesophagus Calcification of the mitral valve may be observed. Later enlargement of the pulmonary artery and of the right ventricle occurs.