Auscultatory and Phonocardiographic Signs of Pulmonary Stenosis

Abstract

The course and management of pulmonary stenosis depends on two main factors, the degree of obstruction to right ventricular outflow and the presence and extent of an over-riding aorta with a ventricular septal defect. This investigation was undertaken to determine how accurately these points could be decided by study of the heart sounds and murmurs. The pulmonary systolic murmur has long been recognized as the most important sign (Peacock, 1866), but the significance of its duration and graphic form has not been widely appreciated. Little attention has been paid to the first heart sound since Petit in 1902 commented on its snapping quality at the base in some cases. The second heart sound at the pulmonary area has been variously described as accentuated, normal, diminished, or absent: this has been due to failure to differentiate between aortic and pulmonary components of the second sound at the pulmonary area as pointed out by Abrahams and Wood (1951). The present investigation shows that the presence or absence of the pulmonary component and its delay in relation to the aortic component are of considerable help in diagnosis. METHODSeventy patients with pulmonary valvular or infundibular stenosis were studied. The clinical diagnosis was confirmed by cardiac catheterization or angiocardiography in all, and also by operation in thirty-five and by necropsy in three cases.Auscultation was always carried out by one of us and the intensity of heart sounds and murmurs was graded, the classification of Freeman and Levine (1933) being used for systolic murmurs. Special attention was paid to the first and second heart sounds, and to the intensity and length ofthe systolic murmur. Highfrequency phonocardiograms corresponding to auscultation (Leatham, 1952) were taken in every case, and were repeated in six after operation. Simultaneous recordings were made from the pulmonary and mitral areas together with an electrocardiogram and an indirect carotid pulse tracing in every case, and synchronously with a pressure pulse from the pulmonary artery and right ventricle in eleven cases. The mitral and tricuspid components of the first sound and the ejection sound were identified by methods already described (Leatham, 1954). The aortic component of the second sound was identified by its relation to the dicrotic notch of the carotid tracing allowing for a delay of from 0-02 to 0104 second. The pulmonary component was identified by its maximum intensity at the pulmonary area and by its synchrony with the dicrotic notch of the tracing from the pulmonary artery when this was obtained simultaneously. The two components of the second heart sound were also identified by taking synchronous phonocardiograms from the pulmonary and mitral areas, since only the aortic component is transmitted to the apex (Leatham, 1954).The duration of right ventricular systole was estimated by measuring the time interval between the tricuspid component of the first sound and the pulmonary component of the second. In the same way left ventricular systole was ...

Determinants of Duration and Mean Rate of Ventricular Ejection

“…In contrast, in patients with patent ductus arteriosus, in whom the stroke volume of the left ventricle exceeds that of the right, abolition or reversal of the normal splitting has been observed. 18 The data shown in figure 6 indicate that pronounced elevation of resistance to ventricular pjection results in its prolongation and may help to explain the wideuing of the normal splitting in pulmonic stenosis 19 and the observed abolition and even reversal of the normal splitting in aortic stenosis. 18 It is self-evident that, with the exception of the slight changes in the duration of isometric contraction and relaxation which might occur, 4 those factors modifying the duration and mean rate of ventricular ejection have a reciprocal influence on the duration and mean rate of ventricular filling.…”

Physiologic Differentiation of Pulmonic Stenosis with and without an Intact Ventricular Septum

“…In pulmonic stenosis the site of pressure change was judged to be at the level of the valve in 35 34 and this was proved in the only one operated on. In the patients with pulmonic stenosis a Bernouilli effect (a negative systolic pressure in the pulmonary arterial tracing) was present in 22, absent in 17, and doubtful in 2.…”

Time‐Domain Analysis of Heart Sound Intensity in Children with and without Pulmonary Artery Hypertension: A Pilot Study using a Digital Stethoscope

“…We compared the relative intensity of the heart sound recordings at the apex and at the 2nd LICS in subjects whose mPAp was less than 25 mmHg (normal) with that in subjects whose mPAp was at least 25 mmHg (pulmonary hypertension) by comparing the ratios of the heart sound intensity S2 ∶ S1, P2 ∶ A2, and P2 ∶ S2 (Figs. [3][4][5].…”