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As the mitral stenosis worsens, the pressure increases, leading to earlier opening of the mitral valve and a shortening of the interval from aortic closure to mitral valve opening also known as aortic closure to opening snap (A2-OS). Often, because the mitral valve is thickened and has lost some pliability, patients may present with a component of mitral regurgitation. Without considerable pressure overload of the left atrium (in the setting of early, mild mitral stenosis), this systolic murmur is generally holosystolic and begins with the first heart sound. As the mitral stenosis worsens (in the

setting of moderate-severe stenosis), the pressure in the left atrium increases and mitral regurgitation murmur is shortened.