The ejection click of valvular pulmonic stenosis

The maverick heart sound

CLINICAL INTRODUCTION

An asymptomatic 29-year-old woman presented for prenatal counselling. She had a history of a heart murmur since childhood and a previous echocardiogram suggesting 'enlargement of the heart'. Physical exam revealed normal jugular venous pressure and contour. Precordial palpation was unremarkable. Auscultation, however, was abnormal; findings on inspiration and expiration are presented in Figure 1, sound clip.

QUESTION

Based on the phonocardiogram and online supplementary audio clip, which of the following is correct? An early diastolic filling sound (S3) is heard, indicating increased right ventricular filling pressures.An ejection click without respiratory variation and a systolic ejection murmur are heard, consistent with bicuspid aortic valve stenosis.An ejection click with respiratory variation and a systolic ejection murmur are heard, consistent with pulmonic valve stenosis.A holosystolic murmur with inspiratory augmentation is heard, indicating tricuspid regurgitation.

Differentiation of cardiac murmurs by dynamic auscultation

The techniques described in this monograph will aid in the accurate identification of the origin of a cardiac murmur or abnormal heart sound. They do not necessarily reveal the presence or severity of cardiac disease. No maneuver is 100% accurate in elucidation of cardiac abnormalities, and a given maneuver's effectiveness varies in its application. The systematic application of a combination of maneuvers improves the accuracy of diagnosis. Auscultatory findings must be interpreted with consideration of the total clinical examination including history, other physical findings, ECG, chest x-ray, and possibly an echocardiogram. Thus, the careful physiological approach to the physical examination represents a powerful noninvasive tool that can be used in combination with other information to accurately diagnose cardiac disease in many patients and efficiently direct further evaluation when necessary.

The physiologic mechanisms of cardiac and vascular physical signs

Examination of the heart and circulation includes five items: 1) the patient's physical appearance, 2) the arterial pulse, 3) the jugular venous pulse and peripheral veins, 4) the movements of the heart--observation, palpation and percussion of the precordium, and 5) auscultation. This report deals with specific examples that relate cardiac and vascular physical signs to their mechanisms, focusing on each of the five sources. It draws liberally on early accounts, emphasizing that modern investigative techniques often serve chiefly to verify hypotheses posed in the past.

Evaluation of heart sounds and murmurs in children

Auscultation is the core of pediatric cardiovascular evaluation and should be performed according to a routine. The four heart sounds should be sought in order at their usual locations, with particular attention to the second sound because of its important diagnostic role in congenital cyanotic heart disease. The next sounds to listen for are clicks, which can be systolic, pulmonary, aortic, or midsystolic. Finally, murmurs should be sought in systole and then diastole. Besides being identified as systolic, diastolic, or continuous, murmurs should be characterized according to their relationship with the first and second heart sounds, intensity, frequency, and maximum location and radiation.

Echocardiographic correlate of presystolic pulmonary ejection sound in congenital valvular pulmonic stenosis

A presystolic ejection click was present in a patient with congenital valvular pulmonic stenosis. The coincidence of this sound with presystolic pulmonary valve opening was demonstrated by simultaneous phonoechocardiography. Hemodynamic confirmation of this observation was made by demonstrating presystolic crossover of RV-PA pressures. This sound was distinguished on phonocardiogram as a high frequency sound separate from a lower frequency presystolic (S4) gallop.

Pulmonary valve echo motion in clinical practice

Examination of the pattern of pulmonary valve echo motion provides useful diagnostic information in a variety of clinical situations. This report describes the normal patterns and variations in pulmonary valve echo motion. It further discusses the applications and limitations of M-mode and cross-sectional echocardiography in detecting obstruction to right ventricular outflow at both the valvular and infundibular level; the wide ranging effects of increases in pulmonary artery pressure on the pulmonary valve echogram; and alterations in right ventricular compliance and volume which may combine to produce diastolic opening of the pulmonary valve. It is emphasized that the thin pliable pulmonary leaflets move in response to local alterations in pressure and flow. The patterns of pulmonary valve echo motion, therefore, although not specific for any particular clinical disorder, may provide valuable, indirect information concerning local pressure and flow characteristics and, as such, may prove extremely helpful when applied to a specific clinical situation.

First heart sound and ejection sounds. Echocardiographic and phonocardiographic correlation with valvular events

To provide additional information on the relation of valvular events to the principal components of the first heart sound (s1), combined echocardiograms and phonocardiograms were recorded in 49 subjects, chosen because of audible splitting of S1 or a combination of S1 and an ejection sound. The subjects included 14 normal persons, 16 patients with a variety of predominantly right-sided heart conditions, 7 with mitral stenosis, 3 with pulmonary stenosis and 9 with aortic valve disease or systemic hypertension. A precise relation was found between completion of closure of the atrioventricular (A-V) valves manifested in the echocardiogram and the high-frequency components of S1 (M1 and T1). The average time from the Q wave of the electrocardiogram to M1 was 0.06 plus or minus 0.003 second and the Q-T1 interval was 0.09 plus or minus 0.002 second. In mitral stenosis the Q-M1 interval was delayed to 0.10 plus or minus 0.005 second, resulting in some instances in reversed splitting of S1. In pulmonary stenosis, the ejection sound occurred 0.10 plus or minus 0.003 second from the Q wave. In 7 of the 16 patients with various right-sided abnormalities, but without valvular stenosis, an ejection sound of pulmonary origin occurred 0.18 plus or minus 0.012 second from the Q wave. In the nine patients with aortic valve disease or systemic hypertension, the time from the Q wave to the aortic ejection sound was 0.13 plus or minus 0.004 second. With only two exceptions the ejection sounds of aortic and plumonary origin coincided exactly with achievement of a fully opened position of the respective semilunar valve. Our findings support the postulate that M1, T1 and the ejection sounds occur in association with closing or opening of valves with consequent sudden deceleration or acceleration of a column of blood that, in turn, results in vibrations of the cardiohemic system and audible sounds.

Genesis, frequency, and diagnostic significance of ejection sound in adults with tetralogy of Fallot

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