Ejection Sounds & Systolic Clicks Chapter 11

1
Ejection Sounds Systolic ClicksChapter 11

• Are G. Talking, MD, FACC
• Instructor
• Patricia L. Thomas, MBA, RCIS

2
Outline

• Ejection Sounds
• Aortic Ejection Sounds
• Pulmonic Ejection Sounds
• Systolic Clicks
• Mitral Valve Prolapse
• Other Causes

3
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

4
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

5
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

6
(No Transcript)
7
(No Transcript)
8
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

9
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

10
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

11
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

12
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

13
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.

14
(No Transcript)
15
(No Transcript)
16
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

17
Systolic Clicks

• Refers to sounds usually heard during mid-to-late
  systole that have a click-like quality.
• Hallmark of mitral valve prolapse

18
(No Transcript)
19
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

20
THE END OF CHAPTER 11

• Tilkian, Ara MD Understanding Heart Sounds and
  Murmurs,
• Fourth Edition, W.B. Sunders Company. 2002, pp.
  121-130