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Mitral Facies
Sometimes patients with mitral stenosis have a dusky red or purple tinge to their
cheeks. This sign is neither sensitive (as many patients with mitral stenosis do not
have it) nor specific (as there are many other reasons for this appearance). It results
from dilated small blood vessels within the skin over the cheeks.
When it does occur, it is usually associated with moderate or severe mitral stenosis
and many believe it is a result of longstanding pulmonary hypertension, because
other causes of pulmonary hypertension may also lead to this appearance. A
chronically low cardiac output, associated with severe mitral stenosis may also
contribute.
Other causes of a “malar flush”
“Weather-beaten” appearance- eg farmers working outside for prolonged periods
Pulmonary arterial hypertension from other causes, sometimes associated with
hypoxia causing secondary polycythaemia
• Polycythaemia rubra vera
• Idiopathic / constitutional
•
•
Link with pulmonary hypertension
Although referred to as “mitral facies” it is NOT associated with mitral regurgitation
(MR), and this may help explain the aetiology because MR is not usually a cause of
pulmonary hypertension. The mechanism by which mitral stenosis causes pulmonary
hypertension is summarised in the diagram:
Mitral stenosis
High LA pressure
Pulmonary venous
hypertension
Pulmonary arterial
hypertension
Right ventricular hypertrophy
 Dr R Clarke
Loud HS1
Kerley B lines
Loud P2
Prominent “a”
wave in JVP
+/- pulmonary
regurgitation
Left parasternal
“heave”
Tricuspid regurgitation
“v” wave in JVP
Right heart failure
Raised JVP
oedema, ascites
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Why do vessels dilate?
The precise reason why vessels in the skin dilate and form abnormal anastomoses is
not clear, but may well be due to a combination of hypoxia, polycythaemia and
reduced cardiac output.
Clinical implications
The main clinical implication is to note such skin changes over the cheeks and to
make a careful check for mitral stenosis in such a patient, looking for:
Pulse- atrial fibrillation (very common), sometimes reduced pulse volume in severe
stenosis
JVP- prominent “A” wave
Apex- tapping due to loud first heart sound
RV- may be prominent left parasternal impulse if pulmonary hypertension
Auscultation: Diaphraghm: loud first heart sound + opening snap if valve still mobile +
loud pulmonary second sound if pulmonary hypertension present.
Bell: localised rumbling murmur at apex with bell lightly applied.
NB: Graham Steele murmur: this is an early diastolic murmur of pulmonary
regurgitation secondary to severe pulmonary hypertension.
 Dr R Clarke
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