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Auscultatory
findings Ejection sounds can be confused with split first heart sounds. However, ejection sounds occur somewhat later than the tricuspid component of a split S1, and is also usually louder and higher in pitch. The ejection sounds are usually occurring about 40 to 100 ms after S1, while the split S1 is usually 20 to 40 ms between the mitral and tricuspid closure. The S1 to ejection sound interval is relatively constant, while the split S1 may vary with changes in the patient position. The splitting of S1 is best heard over the fourth intercostals space, while the Ejection sound is much less pronounced here. Ejection sounds are best heard over the pulmonic and aortic area and over the apex. It is important to establish S1 with certainty and this can easily be done by palpating the patient when listening. S1 coincides with the onset of systole, and you can feel the pulse occurring at this time. Thereby fourth heart sound can be ruled out, which may be a cause of confusion; one may think that the combination S4 + S1 is heard, while in fact there is S1 + Ejection sound. (S4 is occurring late in diastole, just prior to S1) In the phonocardiogram, the EKG tracing reveals this easily. The fourth heart sound is also lower in pitch that the ejection sound. It is important to develop a sense of timing of the systole. When hearing Ejection Sounds, one may also think of Systolic clicks associated with Mitral Valve Prolapse, but this click (single or multiple) occur later in systole. A systolic murmur is often present with ejection sounds |