This document discusses heart sounds and their clinical significance. It describes the two main types of heart sounds as well as abnormal heart sounds including splitting of S1 and S2. Specific heart sounds are examined in different cardiac conditions. S1 components mitral closure (M1) and tricuspid closure (T1) are defined. Abnormal splitting of S1 and S2 are described in various cardiac diseases. Other sounds like S3, S4, ejection sounds, opening snaps are also detailed along with the factors affecting their production and interpretation.
Echocardiographic screening for rheumatic heart diseaseRamachandra Barik
RHD affects ≈20 million people worldwide
highest in developing countries
significant morbidity and mortality
Subclinical detection adds to of secondary prophylaxis
echocardiographic definitions evolving
In 2012, the WHF published evidence-based
guidelines for the echocardiographic diagnosis of RHD
but these criteria have not yet been applied
Echocardiographic screening for rheumatic heart diseaseRamachandra Barik
RHD affects ≈20 million people worldwide
highest in developing countries
significant morbidity and mortality
Subclinical detection adds to of secondary prophylaxis
echocardiographic definitions evolving
In 2012, the WHF published evidence-based
guidelines for the echocardiographic diagnosis of RHD
but these criteria have not yet been applied
The Norwood procedure is the first of three surgeries required to treat single-ventricle conditions such as hypoplastic left heart syndrome (HLHS). Because the left side of the heart can’t be fixed, the series of surgeries rebuilds other parts of the heart.
The Norwood procedure is performed in the baby’s first or second week of life.to redirect the blood flow.
Three goals for the Norwood procedure:
1, Build a new aorta.
2, Direct blood from the right ventricle through the new aorta and on to the rest of the body.
3, Direct the right ventricle to pump blood to the lungs until the next surgery.
Heart murmurs are heart sounds produced when blood flows across one of the heart valves that is loud enough to be heard with a stethoscope.
There are two types of murmurs. A functional murmur or "physiologic murmur" is a heart murmur that is primarily due to physiologic conditions outside the heart. Other types of murmurs are due to structural defects in the heart itself. Functional murmurs are benign (an "innocent murmur").[1]
Murmurs may also be the result of various problems, such as narrowing or leaking of valves, or the presence of abnormal passages through which blood flows in or near the heart. Such murmurs, known as pathologic murmurs, should be evaluated by an expert.
The Norwood procedure is the first of three surgeries required to treat single-ventricle conditions such as hypoplastic left heart syndrome (HLHS). Because the left side of the heart can’t be fixed, the series of surgeries rebuilds other parts of the heart.
The Norwood procedure is performed in the baby’s first or second week of life.to redirect the blood flow.
Three goals for the Norwood procedure:
1, Build a new aorta.
2, Direct blood from the right ventricle through the new aorta and on to the rest of the body.
3, Direct the right ventricle to pump blood to the lungs until the next surgery.
Heart murmurs are heart sounds produced when blood flows across one of the heart valves that is loud enough to be heard with a stethoscope.
There are two types of murmurs. A functional murmur or "physiologic murmur" is a heart murmur that is primarily due to physiologic conditions outside the heart. Other types of murmurs are due to structural defects in the heart itself. Functional murmurs are benign (an "innocent murmur").[1]
Murmurs may also be the result of various problems, such as narrowing or leaking of valves, or the presence of abnormal passages through which blood flows in or near the heart. Such murmurs, known as pathologic murmurs, should be evaluated by an expert.
A brief overview of Cardiac Auscultation followed by a description of the origin of various sounds produced by the heart from a bio-mechanical perspective
Dr. Amit kumar Suresh Rathi*, Dr. Vinod Gite, Dr. Kanchan Rahul Tadke
ABSTRACT- INTRODUCTION: Hoarseness of voice is a very common symptom seen in the ENT outpatient department. Vocal cord palsy due to cardiac diseases and conditions are very less reported .Ortners syndrome or cardiovocal syndrome is one of it, which constitutes hoarseness of voice due to left recurrent laryngeal nerve involvement in cardiovascular disease.
CASE REPORT : A 40 year old lady was referred to ENT outpatient department by the physicians for hoarseness of voice. Patient had hoarseness since 10months; there was no history of smoking, alcohol abuse, voice abuse or upper respiratory tract infection. On complete ENT examination including the indirect laryngoscopy left vocal cord was found to be immobile. Other ENT examination was normal.
DISCUSSION: Hoarseness of voice due to paralysis of the left recurrent laryngeal nerve caused by a dilated left atrium in mitral stenosis was first discussed by Nobert Ortner, a Viennese physician, in1897. He explained that hoarseness was caused by compression of the left recurrent laryngeal nerve by the enlarged left atrium. Later it was described with other identifiable cardiovascular diseases associated either with left atrial enlargement including mitral regurgitation and atrial myxoma or severe pulmonary hypertension including congenital heart diseases. For this reason it is also known as cardiovocal syndrome.
CONCLUSION: For an ENT surgeon, in a case of clinical fix, when all possible causes of the vocal cord palsy are ruled out, a complete cardiovascular examination should be sought.
Key-words: Ortners syndrome, Left recurrent laryngeal nerve palsy, Mitral stenosis, Cardiovocal syndrome
Perioperative evaluation of difficult clinical scenarios which prompted to delay of surgery:
- Undiagnosed aortic regurgitation
- Pleural effusion with suspected TB
In this ppt, I am going to discuss the role of ICD in the patient with Non-ischemic cardiomyopathy. I am going to discuss all the major trials done in the patient with non-ischemic cardiomyopathy.
2015 Jones criteria for the diagnosis of rheumatic feverPRAVEEN GUPTA
In this ppt, I am going to discuss 2015 Jones criteria for the diagnosis of rheumatic fever and various modification made into it and basis for those modifications
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
2. Heart sound
Two types
High-frequency, abrupt terminal checking
of valves,closing or opening
Mitral and tricuspid closing sounds (M1,
T1), nonejection sounds, opening snaps,
aortic and pulmonic closure sounds (A2,
P2) and early valvular ejection sounds
Low-frequency, S3 and S3 gallop ,S4
gallop
2
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
3. Heart Sound S1
Two components
Audible at left lower sternal border
Louder M1 followed by T1
Deceleration of blood setting cardiohemic
into vibration
3
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
4. Spltting of S1
Normal wide splitting,normal (M1, T1)
Right bundle-branch block
LV pacing
Ectopic beats
Idioventricular rhythms from LV
Reversed splitting (T1, M1)
Pacing from the RV
Ectopic beats and idioventricular
rhythms from RV
4
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
5. Factors determining intensity of S1
Integrity of valve closure
Mobility of the valve
Velocity of valve closure
Status of ventricular contraction
Transmission characteristics of the
thoracic cavity and chest wall
Physical characteristics of the
vibrating structures
5
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
6. Integrity of Valve Closure
In severe MR, inadequate coaptation of
the mitral leaflets to a degree that valve
closure is not effective, S1 markedly
attenuated
6
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
7. Mobility of the Valve
Severe calcific fixation of the
mitral valve with severe MS
complete immobilization,
attenuated M1
7Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
8. Velocity of Valve Closure
Relation of S1 with PR interval
PR decreases from 130 to 30 ms increase
in the intensity of M1
Mitral leaflets are maximally separated
At longer PR intervals, there is less
separation of the mitral valve leaflets
Variable S1
Complete AV block with AV dissociation
Mobitz type I AV block
Ventricular tachycardia with AV
dissociation
Atrial fibrillation
8
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
9. Status of Ventricular Contraction
Exercise and catecholamine infusion increase the amplitude of S1
β-blocking agents decreases
S1 is increased in anemia, arteriovenous fistulas, pregnancy, anxiety, and fever.
Loud T1 in an ASD
decrease in the intensity of S1 myxedema, cardiomyopathy, and acute MI
9
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
10. Transmission Characteristics of the Thoracic Cavity and
Chest Wall
Obesity
Emphysema
Large pleural
Pericardial effusions
Decrease the intensity of all auscultatory events,
Thin body habitus increase the intensity
Physical Characteristics of the Vibrating Structures
MI and ischemia induced by pacing decrease the intensity of S1
10
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
11. S1 in Mitral Stenosis
A loud M1
Loud OS,
Calcific fixation of the stenotic MV occurs, M1 is soft, and the OS is absent
11
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
12. S1 in Mitral Valve Prolapse
Loud M1 heard over apex with nonrheumatic MR; indicate holosystolic MVP
Increased amplitude of leaflet excursion with prolapse beyond the line of closure
explains the loud M1 associated with holosystolic prolapse
Middle to late systolic prolapse have a normal S1
Soft or absent S1 indicate a flail mitral leaflet
12
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
13. S1 in LBBB
M1 decreased in intensity and delayed, reversal S1 sequence
LBBB (Delay in onset of LV contraction,LV dysfunction)
Acute AR attenuation or absence of M1 (Increase in the LVEDP, premature closure
of the mitral valve)
13
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
14. Systolic Ejection Sounds
Originate from left or right of the heart
Valvular from deformed aortic or
pulmonic valves
Vascular or root, rapid, forceful ejection
of blood into the great vessels
Root ejection sounds indicate
abnormalities of great vessels with or
without systemic or PHT
Definine level of outflow tract obstruction
14
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
15. Aortic Valvular Ejection Sounds
Nonstenotic congenital bicuspid
valves (Mild to severe stenosis )
With ejection murmur of AS
Widely transmitted
Heard best at the apex
20 to 40 ms after pressure rise onset
in aorta
Ejection click associated with aortic stenosis due to a congenitally bicuspid
valve. Note the high-frequency, high-amplitude sound that follows S1 and is
coincident with the onset of ejection into the aorta. The aortic ejection sound is
formed by sudden cessation of the opening motion of the abnormal valve leaflets
(doming). Note also the delayed carotid upstroke and long systolic
murmur. (From Abrams J: Synopsis of Cardiac Physical Diagnosis. 2nd ed.
Boston, Butterworth Heinemann, 2001, p 135.)
15Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
16. Aortic Valvular Ejection Sounds
With sharp anacrotic notch on the
upstroke of the aortic pressure curve
With maximal excursion of the
domed valve when elastic limits are
met
Intensity of sound correlates directly
with mobility of valve
No correlation between intensity and
severity of the obstruction
Ejection click associated with aortic stenosis due to a congenitally bicuspid
valve. Note the high-frequency, high-amplitude sound that follows S1 and is
coincident with the onset of ejection into the aorta. The aortic ejection sound is
formed by sudden cessation of the opening motion of the abnormal valve leaflets
(doming). Note also the delayed carotid upstroke and long systolic
murmur. (From Abrams J: Synopsis of Cardiac Physical Diagnosis. 2nd ed.
Boston, Butterworth Heinemann, 2001, p 135.)
16Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
17. Pulmonic Valvular Ejection Sounds
Occurs at maximal excursion of the
stenotic pulmonic valve
Pulmonic ejection click decreases with
inspiration in mild to moderate PS
17
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
18. Vascular Ejection Sounds
Originating from aortic root
Common in HTN with tortuous sclerotic aortic root
Coincident with the upstroke of central aortic pressure
Sound occurs at the moment of complete opening of the aortic valve
Tend to be poorly transmitted from the aortic area and are not heard well at the apex
Interpreted as an exaggeration of the ejection component of the normal S1
18
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
19. Pulmonary Vascular Ejection Sounds
From pulmonary artery & due to dilatation of the pulmonary artery
Dilatation can be idiopathic or secondary to severe PH
Louder during expiration
Louder in 2ND and 3RD left intercostal spaces
Occurring during upstroke of pulmonary artery pressure recording
19
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
20. Nonejection Sounds
Midsystolic click
Prolapse of the mitral or tricuspid
valve
With a systolic regurgitant
murmur
20
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
21. Nonejection Sounds
Sharp
High-frequency
Clicking quality
Confined to the apex
Transmitted widely on the precordium
Can isolated finding
In middle to late systole
Can be multiple clicks
21
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
22. Nonejection Sounds
Occurs at time of maximal prolapse
Upright posture, click moves earlier
Squatting, click toward S2
Differentiating nonejection click
from early ejection sounds, a split S2,
or an S3
22Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
23. Heart sound (S2)
High-frequency
Two component, A2 and P2
Produced by the sudden deceleration of
retrograde flow of the blood column in the
aorta and pulmonary artery
Increased intensity of A2 and P2 in
systemic and PH
23
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
24. Normal Physiologic Splitting
In expiration, A2 & P2 separated by <30
ms
Heard by the clinician as a single sound
During inspiration, both components
audible ,caused by a delayed P2
P2 softer than A2 and rarely audible at apex
When P2 is heard at the apex significant
PH is present
Single S2 during both phases of respiration
normal in subjects older than 40 years of
age
24
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
25. Abnormal Splitting of S2
Exists by presence of audible expiratory
splitting (>30 ms)
Must be present in both the supine and
upright
There are three causes of audible expiratory
splitting
(1) wide physiologic splitting primarily
caused by delayed P2,
(2) Reversed splitting primarily caused by
delayed A2
(3) narrow physiologic splitting as seen in
PH, where A2 and P2 are heard as two distinct
sounds during expiration at a narrow splitting
interval.
25
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
26. Wide physiologic splitting of S2
Right bundle-branch block
Severe PH and PS
ASD
Acute MR
Idiopathic dilatation of the pulmonary artery
Mild PS with aneurysmal dilatation of the pulmonary artery
26
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
27. Reversed splitting of S2
Caused by a delay in A2
P2 preceding A2.
Paradoxical movement of A2 and P2
with respiration
During inspiration, P2 moves toward
A2, and the splitting interval narrows
During expiration, the two
components separate, and audible
expiratory splitting is present
Indicates cardiovascular disease
27
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
28. Reversed splitting of S2
RV ectopic and paced beats
Complete LBBB
Hypertrophic cardiomyopathy
Valvular AS,
Hypertensive cardiovascular diseas ( rare)
Ischemic heart disease
Episodes of angina pectoris
Poststenotic dilatation of the aorta
Chronic AR
Patent ductus arteriosus
Type B Wolff-Parkinson-White syndrome
28
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
29. Narrow Physiologic Splitting
Common finding in severe PH
In contrast to the normal situation, where only a single sound is heard during expiration, both
A2 and P2 are easily heard, even though the splitting interval is less than 30 ms because of the
increased intensity and high-frequency composition of P2
Wide, persistent splitting sign of abnormal RV performance in patients with primary PH
Fixed splitting of S2 occasionally has been documented in severe RV failure secondary to PH.
29
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
30. Single S2
Delay A2 produce when splitting interval
<30 ms
One component of S2 is either absent or
inaudible
Eisenmenger VSD
Inability to hear the fainter of the two
components of the sound (usually P2)
because of emphysema, obesity, or
respiratory noise
Seen in older than 50 years of age
30
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
31. Opening Snaps
Opening of AV valve silent event
With thickening and deformity of the
leaflets sound is generated in early diastole
High-frequency
Early diastolic sound
Absent in thickened and immobile valves
31
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
32. Opening snap
Crisp
Sharp sound
Heard in the midprecordial location
Best in the area from the left sternal
border to just inside the apex
Often heard well at the base of the heart
Diastolic rumble follows opening snap
No variation in the intensity or timing of
the mitral opening snap with respiration
32
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
33. Opening snap
Intensity correlates with valve
mobility
Loud in mobile stenotic valves
Absent with severe calcific valve
Intensity of M1 parallels the intensity
of the opening snap
The opening snap occurs at the
maximal mitral valve opening shortly
after LV–left atrial pressure
crossovers.
33
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
34. Factors that influence the timing of the opening snap
relative to A2
Rate of LV pressure decline
Level of the LV pressure at the time of A2
Level of the left atrial pressure
Increasing severity of MS,shortening of
the A2–opening snap interval
Imperfect correlation between A2–
opening snap interval and mitral area
A2–opening snap interval in atrial
fibrillation vary with cycle length
34
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
35. Differential diagnosis of opening snap
Differentiated from other early diastolic sounds S3, the pulmonary component of a widely split S2
35
36. Third and Fourth Heart Sounds
Low-frequency
Related to early and late diastolic
filling of the ventricles
Disease states called gallop sounds
Gives information of ventricular
function and compliance
36
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
37. Third heart sound (S3)
Physiologic S3 benign finding
Commonly in children, adolescents,
and young adults
Rarely after 40 years of age, when
present associated with a thin,
asthenic body
Low-frequency sound that
Follows A2 by 120 to 200 ms
37
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
38. Third heart sound (S3)
Occurs during rapid filling of the ventricle
Best heard at the apex
In left lateral position
Stethoscope's bell pressed lightly against
skin
Differentiated from the pathologic S3
primarily by the "company it keeps."
38
RV S3 heard at the lower left sternal edge
and increase in intensity with inspiration
LV systolic dysfunction
Diuresis, S3 decreases
S3 with cardiomyopathy/Myocardial
infacrtion ominous sign
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
39. Third heart sound(S3)
Chronic AR
Acute AR
AV valve regurgitation
Large left-to-right shunts
VSD
Patent ductus arteriosus
ASD
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy
39
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
40. Fourth Heart Sound (S4)
Best heard at the apex
In left lateral position
Varies with respiration
Heard best during expiration
S4 just prior to S1
Also termed atrial diastolic gallop or the
presysolic gallop
Atrial contraction must be present for S4
Absent in atrial fibrillation
40
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
41. Fourth Heart Sound (S4)
Audibility depends on its intensity and frequency, separation from S1
Degree of separation is determined primarily by PR interval
A loud S1 also can mask the audibility of a preceding softer S4
Left-sided S4 and S3 augmented post-tussively and sustained handgrip exercise
Maneuvers that increase venous return increase the audibility by increasing the intensity of
the sound and by causing it to occur earlier, thereby separating it further from S1.
Decreased venous return does the opposite
Accompanied by a palpable presystolic apical impulse
S4 generated by right atrial contraction heard best at the lower left sternal border
Accentuated with inspiration
41
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
42. Fourth Heart Sound(S4)
Systemic hypertension
Severe valvular AS
Hypertrophic cardiomyopathy
42
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
43. Prosthetic valves sound
Type of valve,
its position,
whether it is functioning normally
Mechanical valves produce opening and closing clicks
Are easily audible
Can be heard even without a stethoscope.
Ball-in-cage valves produce the loudest and most distinctive opening and closing clicks
The metallic ball of the Starr-Edwards valve also produces multiple early systolic clicks
Absence or decrease in intensity of clicks occur with valve obstruction or LV dysfunction.
A decrease in the intensity of the opening and closing clicks, and the absence of the opening
click are also indications of valve malfunction.
43Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
45. Extracardiac Sounds
Pacemaker Sounds
High-frequency sounds of brief duration with transvenous pacemakers located in
the RV apex
Extracardiac in origin
within 6-10 ms with the pacemaker spike
caused by stimulation of intercostal nerves adjacent to endocardial electrodes
Should suggest myocardial perforation by the endocardial lead
45
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
46. Pericardial Friction Rub
Inflammation of the pericardial sac with or without fluid
Very high pitched
Leathery
Scratchy in nature
Seem close to the ear
Auscultated best with the patient leaning forward or knee–chest position
Holding his or her breath after forced expiration
46
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
47. Pericardial Friction Rub
Three components
Atrial systole,
Ventricular contraction
Rapid early diastolic filling
Uremic pericarditis
Acute phase of transmural MI
47
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.
48. Mediastinal Crunch: Hamman Sign
When air is present in the mediastinum
Scratchy sounds (Hamman sign) occur
Related indirectly to both heartbeat and
respiratory excursion
Occur most frequently during ventricular
systole
Caused by air in the mediastinum
Common after cardiac surgery
48
Hurst J, Fuster V, Walsh RA. Hurst's the Heart. McGraw-Hill Medical; 2011.