Split S2 From Wikipedia, the free encyclopedia A split S2 is a finding upon auscultation of the S2 heart sound.

[1] It is caused when the closure of the aortic valve (A2) and the closure of the pulmonary valve(P2) are not synchronized.[2] [edit]Physiologic split During inspiration, the chest wall expands and causes the intrathoracic pressure to become more negative (think of a vacuum). The increased negative pressure allows the lungs to fill with air and expand. While doing so, it also induces an increase in venous blood return from the body into the right atrium via the superior and inferior vena cavae, and into the right ventricle by increasing the pressure gradient (blood is being pulled by the vacuum from the body and towards the right side of the heart). Simultaneously, there is a reduction in blood volume returning from the lungs into the left ventricle (the blood wants to stay in the lungs because of the vacuum surrounding the lungs). Since there is an increase in blood volume in the right ventricle, the pulmonary valve (P2 component of S2) stays open longer during ventricular systole due to an increase in ventricular emptying time, whereas the aortic valve (A2 component of S2) closes slightly earlier due to a reduction in left ventricular volume and ventricular emptying time. Thus the P2 component of S2 is delayed relative to that of the A2 component. This delay in P2 versus A2 is heard as a slight broadening or even "splitting" of the second heart sound; though it is usually only heard in the pulmonic area of the chest because the P2 is soft and not heard in other areas. During expiration, the chest wall collapses and decreases the negative intrathoracic pressure (compared to inspiration). Therefore, there is no longer an increase in blood return to the right ventricle versus the left ventricle and the right ventricle volume is no longer increased. This allows the pulmonary valve to close earlier such

left ventricular volume and emptying time decreases 5. during inspiration and in the "pulmonary area". opposing the pressure in the pulmonary artery and keeping it . The pressure in the pulmonary artery tries to close the pulmonary valve. Chest wall expands during inspiration 2.e. Pulmonic valve closure is delayed.[3] The pressure in the right ventricle tries to open the pulmonary valve. venous return from the lungs to the left heart decreases 4. Intrathoracic pressure becomes more negative to form a vacuum 3. and the split is no longer heard. due to an increase in blood flow into the right ventricle with displacement of the interventricular septum to the left. decreasing left ventricular filling and cardiac output". the closure of the pulmonary valve (P2) will be delayed since the pressure in the right ventricle is increased in inspiration. aortic valve closure is advanced 6. Remember that the higher pressure will "win". It is physiologically normal to hear a "splitting" of the second heart tone in younger people. [edit]Steps 1. "Normally. blood pressure falls during inspiration (equal or less than 10 mmHg).that it overlaps the closing of the aortic valve. Expiration equalizes filling and emptying times on both sides of the heart eliminating the splitting of S2 [edit]Analysis of pressure According to Harrison's Principles of Internal Medicine. Hence. the 2nd ICS (intercostal space) at the left edge of the sternum. i. Right ventricular volume and emptying time increases. Venous return from the body to the right heart increases. S2 splits into A2 and P2 respectively 7.

When the pulmonary valve closes before the aortic valve. (although RBBB is known to be associated only with S1 split). it is termed a "fixed split S2" and is usually due to a septal defect.open longer than in expiration. The change in A2 is not that evident.[6]  . Aortic stenosis. [edit]Pathologic split The different types of split S2 can be associated with medical conditions:   Split during inspiration: normal.  A bundle branch block either LBBB or RBBB. thereby causing the pulmonary valve to close later than the aortic valve independent of inspiration/expiration. and a ventricular pacemaker could all cause a reverse splitting of the second heart sound.[4] (See above) Split during expiration: Reverse splitting indicates pathology. left bundle branch block (LBBB). The ASD or VSD creates a left to right shunt that increases the blood flow to the right side of the heart. Thus P2 appears after A2 in inspiration.[citation needed] Split during both inspiration and expiration:  If splitting does not vary with inspiration. will produce continuous splitting but the degree of splitting will still vary with respiration. hypertrophic cardiomyopathy.[5] such as an atrial septal defect (ASD) or ventricular septal defect (VSD). this is known as a "paradoxically split S2".

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