Systolic Clicks

Ejection clicks are high-pitched sounds that occur early in systole at the onset of ejection and are produced by the opening of pathologically deformed semilunar valves. Pulmonic or aortic


Normal splitting

Wide splitting

(Pulmonic stenosis, RBBB, mitral regurgitation, VSD, PDA)

Paradoxical splitting (Aortic stenosis, LBBB)

Fixed splitting

(Atrial septal defect)

A2 P

A2 P

P2 A2

Figure 14-35 Abnormalities of splitting of the second heart sound. (RBBB, right bundle branch block; VSD, ventricular septal defect; PDA, patent ductus arteriosus; LBBB, left bundle branch block.)

stenosis may produce ejection clicks. The sounds are short and have the quality of a ''click.'' Pulmonic ejection clicks are best heard at the pulmonic area, and aortic ejection clicks are heard at the aortic area. As calcification progresses, the mobility of the valve decreases, and the ejection click disappears.

Midsystolic clicks are not ejection clicks. They occur in the middle of systole. They may be single or multiple, and they may change in position during the cardiac cycle with various maneuvers that change ventricular geometry. The most common condition associated with a midsystolic click is prolapse of the mitral or tricuspid valve.

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