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 S 1 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 mid- to-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