Pulmonic valvular ejection sounds have identical sound and pressure correlates as aortic valvular ejection sounds.231 Echocardiographic correlations also have shown that the onset of the pulmonary ejection sound occurs at the maximal excursion of the stenotic pulmonary valve. In contrast to the aortic valvular ejection sounds and to most right-sided auscultatory events, the pulmonic sound or ejection click decreases in intensity or disappears with inspiration in mild to moderate pulmonic stenosis. In very mild valvular pulmonic stenosis, respiratory variation may be absent.231 In very severe valvular obstruction, a vigorous atrial contraction can completely preopen the pulmonic valve in diastole, causing a crisp preejection sound. In this situation, RV pressure at the time of the atrial kick actually can exceed pulmonary artery end-diastolic pressure.231 As the severity of the pulmonic stenosis increases, both the excursion of the deformed valve and the RV isovolumic contraction time decrease. The net effect of both these events is migration of the pulmonary ejection sound toward Si.
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