Aortic Valvular Ejection Sounds

Aortic valvular ejection sounds are found in nonstenotic congenital bicuspid valves and in the entire spectrum of mild to severe stenosis of the aortic valve. This sound introduces the typical ejection murmur of aortic stenosis, is widely transmitted, and is often heard best at the apex. The aortic valvular ejection sound is delayed 20 to 40 ms after the onset of pressure rise in the central aorta and is coincident with the sharp anacrotic notch on the upstroke of the aortic pressure curve. The sound is coincident with the maximal excursion of the domed valve when its elastic limits are met.229 The abrupt deceleration of the oncoming column of blood sets the entire cardiohemic system into vibration, the lower-frequency components being recorded as the anacrotic notch and the high-frequency components representing the valvular ejection sound. Inherent in this mechanism of sound production is the ability of the deformed valve to move. With severe calcific fixation of the valve, no excursion or piston-like ascent of the deformed valve is possible; therefore, no sudden tensing of the valve leaflets or abrupt deceleration of the column of blood occurs. Sound and motion correlates identical to those demonstrated by cineangiography have been found with phonoechocardiography, clearly showing the onset of the ejection sound to be coincident with the maximal opening of the valve230 (Fig. 10-66). The intensity of the ejection sound correlates directly with the mobility of the valve, but there is no correlation between intensity and the severity of the obstruction. In mobile, nonstenotic bicuspid valves, the ejection sound is not only loud but also widely separated from S1

due to the prolonged excursion of the mobile valve. The presence of an aortic valvular ejection sound is a valuable physical finding at the bedside; it not only defines the LV outflow obstruction at the valvular level but also gives insight into the mobility of the valve (see Fig. 10-66).

Anacrotic Notch

Figure 10-66: Base and apex phonocardiograms are recorded simultaneously with the aortic valve echocardiogram in a young man with valvular aortic stenosis. A prominent aortic valvular ejection sound (AVES) is recorded at the apex and is coincident with the maximal excursion of the aortic valve in early systole. It is followed by a crescendo-decrescendo systolic ejection murmur (SEM) that ends well before a loud A2.

Figure 10-66: Base and apex phonocardiograms are recorded simultaneously with the aortic valve echocardiogram in a young man with valvular aortic stenosis. A prominent aortic valvular ejection sound (AVES) is recorded at the apex and is coincident with the maximal excursion of the aortic valve in early systole. It is followed by a crescendo-decrescendo systolic ejection murmur (SEM) that ends well before a loud A2.

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