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Heart sounds in Aortic stenosis

First heart sound in AS
S1 is normal or decreased intensity.
It is due to partial closure of mitral valve in presystole. Lound S1 is associated with MS.
A2 in AS
          Loud A2 indicate pliable valve cusp in congenital AS.
          Soft A2 – Occur due to rigid calcific valve.
Comment on split in AS
          Split may be normal.
          Paradoxical split or single S2 can occur.
When will you get normal split in AS
          Occur in mild to moderate AS.
          Split is normal even in congenital MS.
What is the significance of paradoxic split in AS
          Paradoxic split indicate severe AS if there no left bundles branch block (LLBB) . LV dysfunction seen in only 25% of elderly with severe AS.
          Paradoxical split is due to prolonged electromechanical systole which produce delay in A2 component.
What is the significance of single S2 in AS
         Seen in 66% of elderly with severe AS. It is due to absent A2 or due to masked P2 by the murmur. 
Significance of S4 inAS
          It indicate severe AS in the absence of coronary artery disease or hypertension. Palpable S4 always indicate severe AS.
Aortic ejection click
1.    AEC indicate valvular AS with mobile valves.
2.    AEC is common in congenital AS, and bicuspid aortic valve.
3.    It is rare in elderly.
4.    It disappear with valve calcification.
5.    AEC does not correlate with severity of AS.
6.    Amplitude correlate with that of A2.
What are the features of AEC
1.    AEC  occur after S1.
2.   It is best heard at the apex/ aortic area.
3.    There is no variation with respiration.
4.    It is a high pitched sound.
What is AEC
          It is a high pitched sound produced due to the snapping open of the stenotic thickened aortic valve.
Significance of aortic ejection click
1.    It indicate that the stenosis is at valvular level.
2.    The severity of AS is mild.