Split S2

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Wiggers diagram of various events of a cardiac cycle, with 2nd heart sound at bottom. Wiggers Diagram.svg
Wiggers diagram of various events of a cardiac cycle, with 2nd heart sound at bottom.

A split S2 is a finding upon auscultation of the S2 heart sound. [1]

Contents

It is caused when the closure of the aortic valve (A2) and the closure of the pulmonary valve (P2) are not synchronized during inspiration. The second heart sound (S2) is caused by the closure of the aortic and pulmonic valves, which causes vibration of the valve leaflets and the adjacent structures. The aortic valve closes slightly before the pulmonic, and this difference is accentuated during inspiration when S2 splits into two distinct components (physiological splitting). During expiration, the pulmonic valve closes at nearly the same time as the aortic, and splitting of S2 cannot be heard.

Exercise increases the intensity of both the aortic and pulmonic components of S2, whereas deep inspiration increases the intensity of the pulmonic component only.

Physiological split

During inspiration, the chest wall expands and causes the intrathoracic pressure to become more negative (think of a vacuum). The increased negative pressure allows the lungs to fill with air and expand. While doing so, it also induces an increase in venous blood return from the body into the right atrium via the superior and inferior venae cavae, and into the right ventricle by increasing the pressure gradient (blood is being pulled by the vacuum from the body and towards the right side of the heart). Simultaneously, there is a reduction in blood volume returning from the lungs into the left atrium (the blood wants to stay in the lungs because of the vacuum surrounding the lungs, and PVR is lower because of lung expansion). Since there is an increase in blood volume in the right ventricle during inspiration, the pulmonary valve (P2 component of S2) stays open longer during ventricular systole due to an increase in ventricular emptying time, whereas the aortic valve (A2 component of S2) closes slightly earlier due to a reduction in left ventricular volume and ventricular emptying time. Thus the P2 component of S2 is delayed relative to that of the A2 component. This delay in P2 versus A2 is heard as a slight broadening or even "splitting" of the second heart sound; though it is usually only heard in the pulmonic area of the chest because the P2 is soft and not heard in other areas.[ citation needed ]

During expiration, the chest wall collapses and decreases the negative intrathoracic pressure (compared to inspiration). Therefore, there is no longer an increase in blood return to the right ventricle versus the left ventricle and the right ventricle volume is no longer increased. This allows the pulmonary valve to close earlier such that it overlaps the closing of the aortic valve, and the split is no longer heard.[ citation needed ]

It is physiologically normal to hear a "splitting" of the second heart tone in younger people, during inspiration and in the "pulmonary area", i.e. the 2nd ICS (intercostal space) at the left edge of the sternum.

Steps

  1. Chest wall expands during inspiration
  2. Intrathoracic pressure becomes more negative to form a vacuum
  3. Venous return from the body to the right heart increases, venous return from the lungs to the left heart decreases

Analysis of pressure

According to Harrison's Principles of Internal Medicine, "Normally, blood pressure falls during inspiration (equal or less than 10 mmHg), due to an increase in blood flow into the right ventricle with displacement of the interventricular septum to the left, decreasing left ventricular filling and cardiac output". [2]

The pressure in the right ventricle tries to open the pulmonary valve. The pressure in the pulmonary artery tries to close the pulmonary valve. Remember that the higher pressure will "win". Hence, the closure of the pulmonary valve (P2) will be delayed since the pressure in the right ventricle is increased in inspiration, opposing the pressure in the pulmonary artery and keeping it open longer than in expiration. The change in A2 is not that evident. Thus P2 appears after A2 in inspiration.[ citation needed ]

Pathological split

The different types of split S2 can be associated with medical conditions:

When the pulmonary valve closes before the aortic valve, this is known as a "paradoxically split S2". [6] On physical exam, paradoxical splitting is appreciated as increased splitting on expiration relative to inspiration, versus normal splitting where inspiration will increase splitting. It is seen in conditions that delay left ventricular emptying (e.g., aortic stenosis, left bundle branch block).

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Aortic stenosis Medical condition

Aortic stenosis is the narrowing of the exit of the left ventricle of the heart, such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse over time. Symptoms often come on gradually with a decreased ability to exercise often occurring first. If heart failure, loss of consciousness, or heart related chest pain occur due to AS the outcomes are worse. Loss of consciousness typically occurs with standing or exercising. Signs of heart failure include shortness of breath especially when lying down, at night, or with exercise, and swelling of the legs. Thickening of the valve without narrowing is known as aortic sclerosis.

Heart valve A flap of tissue that prevent backflow of blood around the heart

A heart valve is a one-way valve that normally allows blood to flow in only one direction through the heart. The four valves are commonly represented in a mammalian heart that determines the pathway of blood flow through the heart. A heart valve opens or closes incumbent on differential blood pressure on each side.

Heart sounds Noise generated by the beating heart

Heart sounds are the noises generated by the beating heart and the resultant flow of blood through it. Specifically, the sounds reflect the turbulence created when the heart valves snap shut. In cardiac auscultation, an examiner may use a stethoscope to listen for these unique and distinct sounds that provide important auditory data regarding the condition of the heart.

Aortic valve

The aortic valve is a valve in the human heart between the left ventricle and the aorta. It is one of the two semilunar valves of the heart, the other being the pulmonary valve. The heart has four valves; the other two are the mitral and the tricuspid valves. The aortic valve normally has three cusps or leaflets, although in 1–2% of the population it is found to congenitally have two leaflets. The aortic valve is the last structure in the heart the blood travels through before stopping the flow through the systemic circulation.

Heart murmur Medical condition

Heart murmurs are heart sounds produced when blood is pumped across a heart valve and creates a sound loud enough to be heard with a stethoscope. Murmurs are of various types and are important in the detection of cardiac and valvular pathologies.

Systole

The systole is the part of the cardiac cycle during which some chambers of the heart muscle contract after refilling with blood. The term originates, via New Latin, from Ancient Greek συστολή (sustolē), from συστέλλειν, and is similar to the use of the English term to squeeze.

Ventricle (heart) Chamber of the heart

A ventricle is one of two large chambers toward the bottom of the heart that collect and expel blood received from an atrium towards the peripheral beds within the body and lungs. The atrium primes the pump.

Afterload Pressure in the wall of the left ventricle during ejection

Afterload is the pressure that the heart must work against to eject blood during systole. Afterload is proportional to the average arterial pressure. As aortic and pulmonary pressures increase, the afterload increases on the left and right ventricles respectively. Afterload changes to adapt to the continually changing demands on an animal's cardiovascular system. Afterload is proportional to mean systolic blood pressure and is measured in millimeters of mercury.

Pulmonary valve

The pulmonary valve is the semilunar valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. Similar to the aortic valve, the pulmonary valve opens in ventricular systole, when the pressure in the right ventricle rises above the pressure in the pulmonary artery. At the end of ventricular systole, when the pressure in the right ventricle falls rapidly, the pressure in the pulmonary artery will close the pulmonary valve.

Mitral valve stenosis Mitral valve disease that is characterized by the narrowing of the orifice of the mitral valve of the heart

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Atrial septal defect Human Heart defect present at birth

Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this does not naturally close after birth it is referred to as a patent (open) foramen ovale (PFO). It is common in patients with a congenital atrial septal aneurysm (ASA).

Ventricular septal defect Medical condition

A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart. The extent of the opening may vary from pin size to complete absence of the ventricular septum, creating one common ventricle. The ventricular septum consists of an inferior muscular and superior membranous portion and is extensively innervated with conducting cardiomyocytes.

A transthoracic echocardiogram (TTE) is the most common type of echocardiogram, which is a still or moving image of the internal parts of the heart using ultrasound. In this case, the probe is placed on the chest or abdomen of the subject to get various views of the heart. It is used as a non-invasive assessment of the overall health of the heart, including a patient's heart valves and degree of heart muscle contraction. The images are displayed on a monitor for real-time viewing and then recorded.

Cardiac cycle

The cardiac cycle is the performance of the human heart from the beginning of one heartbeat to the beginning of the next. It consists of two periods: one during which the heart muscle relaxes and refills with blood, called diastole, following a period of robust contraction and pumping of blood, dubbed systole. After emptying, the heart immediately relaxes and expands to receive another influx of blood returning from the lungs and other systems of the body, before again contracting to pump blood to the lungs and those systems. A normally performing heart must be fully expanded before it can efficiently pump again. Assuming a healthy heart and a typical rate of 70 to 75 beats per minute, each cardiac cycle, or heartbeat, takes about 0.8 seconds to complete the cycle. There are two atrial and two ventricle chambers of the heart; they are paired as the left heart and the right heart—that is, the left atrium with the left ventricle, the right atrium with the right ventricle—and they work in concert to repeat the cardiac cycle continuously,. At the start of the cycle, during ventricular diastole–early, the heart relaxes and expands while receiving blood into both ventricles through both atria; then, near the end of ventricular diastole–late, the two atria begin to contract, and each atrium pumps blood into the ventricle below it. During ventricular systole the ventricles are contracting and vigorously pulsing two separated blood supplies from the heart—one to the lungs and one to all other body organs and systems—while the two atria are relaxed. This precise coordination ensures that blood is efficiently collected and circulated throughout the body.

Valvular heart disease Disease in the valves of the heart

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

Pulmonary valve stenosis Medical condition

Pulmonary valve stenosis (PVS) is a heart valve disorder. Blood going from the heart to the lungs goes through the pulmonary valve, whose purpose is to prevent blood from flowing back to the heart. In pulmonary valve stenosis this opening is too narrow, leading to a reduction of flow of blood to the lungs.

Pulmonic stenosis, is a dynamic or fixed obstruction of flow from the right ventricle of the heart to the pulmonary artery. It is usually first diagnosed in childhood.

A right-to-left shunt is a cardiac shunt which allows blood to flow from the right heart to the left heart. This terminology is used both for the abnormal state in humans and for normal physiological shunts in reptiles.

Lutembachers syndrome Medical condition

Lutembacher's syndrome is a very rare form of congenital heart disease that affects one of the chambers of the heart as well as a valve. It is commonly known as both congenital atrial septal defect (ASD) and acquired mitral stenosis (MS). Congenital atrial septal defect refers to a hole being in the septum or wall that separates the two atria; this condition is usually seen in fetuses and infants. Mitral stenosis refers to mitral valve leaflets sticking to each other making the opening for blood to pass from the atrium to the ventricles very small. With the valve being so small, blood has difficulty passing from the left atrium into the left ventricle. Septal defects that may occur with Lutembacher's syndrome include: Ostium primum atrial septal defect or ostium secundum which is more prevalent.

The following outline is provided as an overview of and topical guide to cardiology, the branch of medicine dealing with disorders of the human heart. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in cardiology are called cardiologists.

References

  1. "The Auscultation Assistant – Split S2" . Retrieved 9 January 2009.
  2. Loscalzo, Joseph; Charles M. Wiener; Bloomfield, Gerald T.; Fauci, Anthony S.; Braunwald, Eugene; Dennis L. Kasper; Hauser, Stephen L; Longo, Dan L. (2008). Harrison's principles of internal medicine: self-assessment and board review. McGraw-Hill Medical. ISBN   0-07-149619-X. Question 29 disorders of the cardiovascular system
  3. Mayra Perez; Lindsay K. Botsford; Winston Liaw (2007). Deja Review: Family Medicine. McGraw Hill Professional. p. 28. ISBN   978-0-07-148568-5.
  4. Dan Longo. Principles of Internal Medicine. McGraw Hill Medical. pp. 1826–1827. ISBN   978-0-07-174890-2.
  5. Salvatore Mangione (2000). Physical diagnosis secrets. Elsevier Health Sciences. p. 215. ISBN   978-1-56053-164-7.
  6. Ellen Chiocca (2010). Advanced Pediatric Assessment. Lippincott Williams & Wilkins. p. 379. ISBN   978-0-7817-9165-6.