23 Heart Sounds
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S1: closure of MV, LV > LA
S2: closure of AV, LV < aortic pressure
S1: QRS, depolarization of ventricles, contract, close mitral and tricuspid valves
S2: aortic closes first
Splitting
Physiologic
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inspiration: increased venous return to RV, longer for RV to pump blood, delays PV closure
Persistent
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exhalation: some separation of aortic and pulmonic components of S2, increases with inspiration, doesn't go away in exhalation
RBBB: delayed contraction of RV, even during exhalation, PV closure late
PHTN: dilated RV, delayed closure of PV even during exhalation
anything delays contraction of RV: electrical (RBBB) or structural (dilated)
Fixed
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ASD: blood from left to right, always have increased venous return to right, even during exhalation
doesn't change in size during exhalation/inspiration, different from persistent
child with shortness of breath and fixed split S2 = ASD
Paradoxical
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split during exhalation and single during inhalation
exhalation: AV closure delayed
inhalation: venous return delays PV closure, single heart sound
pacemaker: signal to RV first, delayed left closure
HCM: blockage to flow from thickened septum
Pathologic
P2
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S3
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quick moving blood hits wall
pt lie on left side on exam table
Kentucky
between s2 and s1 is diastole
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slams blood hitting stiff wall and making a loud noise, requires atrial kick, can't occur in afib
Tennessee
between s2 and s1 is diastole
Clicks
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sound like click and in systole
normal: leveled plane
MVP: leaflets bellow up into LA, leaflets damaged and stretched, cause click when leaflets snap up into LA like a parachute, small amount of mitral regurge after click
click and holosystolic: sounds like mitral regurge with S3
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