Download Ejection Sounds & Systolic Clicks Chapter 11

Ejection Sounds & Systolic Clicks
Chapter 11
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS
Outline
• Ejection Sounds
– Aortic Ejection Sounds
– Pulmonic Ejection Sounds
• Systolic Clicks
– Mitral Valve Prolapse
– Other Causes
Ejection Sounds
• Ejection Sounds occur about 60 msec after
the first heart sound, with the onset of
ejection through the fully opened aortic or
pulmonic valve
• High pitched, clicky sounds caused by
abnormalities of the pulmonic trunk or
aortic trunk
Aortic Ejection Sounds
• Early systolic, high-pitched clicky sound
heard immediately after the first heart sound
• Two most common causes of aortic ejection
sounds:
– Aortic stenosis
– Congenital bicuspid aortic valve
Congenital Aortic Valvular Stenosis
• The ejection sound coincides with the point
where the domed aortic valve has achieved
its maximum ascent into the aortic and
snaps to a halt because its elastic limits are
met
Bicuspid Aortic Valve
• Bicuspid Aortic Valve has two leaflets
• Very young a single sound of bicuspid
aortic valve
• Adolescents there is a aortic ejection sound
followed by a systolic ejection murmur of
AS
• Adult the aortic valve may calcify and
overtime worsens, loose mobility and the
ejection sound disappears
Other Causes of Ejection Sounds
• Aneurysm of the ascending aorta
• Advanced degree of aortic regurgitation
• Distal obstruction of the aorta (as in
coarctation of the aorta)
• Tetralogy of Fallot
• Hyperdynamic circulatory states, severe
anemia
Where to Listen
• Aortic Ejection Sound listen with
diaphragm of the stethoscope pressed firmly
against the chest wall at the left ventricular
apex and over the aortic area. Aortic events
are well heard at the apex
Pulmonic Ejection Sounds
• High-pitched sound heard in early systole
– Mild to moderate pulmonic valvular stenosis
(with severe pulmonic stenosis, the ejection
sound is difficult to hear)
– Tetralogy of Fallot (heard in about 50% of adult
patients with the condition)
– Pulmonary hypertension caused by dilation of
the proximal pulmonary artery
– Idiopathic dilatation or aneurysm of the
pulmonary artery
Pulmonic Valvular Stenosis
• Ejection Sound
– Abrupt arrest of the rapid upward movement & doming of the
stenotic pulmonic valve
– With ejection of blood through the stenosed pulmonic valve
• Intensity
– Inversely related to the severity of the obstruction
• S1 Ejection Sound Interval
– Severity Increases, interval shortens until in severe stenosis,
there is no ejection sound at all
• Degree of Stenosis
– The tighter the stenosis, the earlier the ejection sound disappears
during inspiration
Pulmonic Valvular Stenosis cont..
• Effect of Respiration
– Pulmonary ejection sound is diminished in intensity
during inspiration, at which time the increased
return of blood to the right heart causes the diastolic
pressure in the RV to rise above that of the PA that
the PV floats to an open position.
– Expiration during diastole the pressure in the RV is
below that of the PA. The stenosed PV remains
domed toward the RV. When the RV begins to
contract, its pressure abruptly rises above that in the
PA, the dome of the stenotic valve is flung into the
PA and suddenly tenses producing the ejection
sound.
Where to Listen
• Listen with the diaphragm of the
stethoscope pressed firmly against the chest
wall in a localized area at the second and
third left intercostal space along the left
sternal border
• Decreases in intensity during inspiration
Systolic Clicks
• Refers to sounds usually heard during midto-late systole that have a click-like quality.
• Hallmark of mitral valve prolapse
Mitral Valve Prolapse
• Clicks are caused by abrupt tensing of a
prolapsed mitral valve leaflet after it has
billowed into the LA during ventricular systole
• Associated with thinning and elongation of the
chordae tendineae
• Where to Listen
– Listen with the diaphragm of the stethoscope at the
apex of the heart with the patient in the left lateral
position
THE END
OF
CHAPTER 11
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp. 121-130