1. Physical examination Body weight is often low ; asthenic Blood pressure is usually normal or low Orthostatic hypotension Thoracic skeletal abnormalities suggesting MVP: – Scoliosis, pectus excavatum, straightened thoracic spine, and narrowed AP dm of the chest Zippes, D., et al. (2005) Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 7 th ed. USA: Elsevier Saunders

2. Auscultation: Nonejection systolic click at least 0.14 sec after S1 Multiple mid and late systolic clicks along the L lower sternal border Mid to late crescendo systolic murmur that continues to A2 Zippes, D., et al. (2005) Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 7 th ed. USA: Elsevier Saunders

3. Dynamic Auscultation: End-diastolic LV volume Critical LV volume is achieved earlier in systole Click-murmur moves closer to S1 LV systolic volume/ afterload Lengthens the time from onset of the systole to MVP Click-murmur moves closer to S2 Zippes, D., et al. (2005) Braunwald’s Heart Disease: A textbook of Cardiovascular Medicine, 7 th ed. USA: Elsevier Saunders

4. Dynamic Auscultation: Response of the Murmur of MVP to Interventions InterventionTimingIntensity Standing upright Recumbent or 0 Squatting or 0 Hand grip + Valsalva + Amyl nitrite + Fuster, V.,et al. (2008). Hurst’s The Heart, 12the ed. China: McGrawHill Co.