The Exaggerated Physiological S3

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List the common shunts and the valvular lesion that may cause excessive flow through the mitral valve, therefore exaggerating or bringing back the physiological S3.

ANS: a. The two left-to-right shunts, ventricular septal defect (VSD) and persistent ductus arteriosus (PDA). (Atrial septal defects [ASDs] do not increase flow through the mitral valve.) b. An incompetent mitral valve, i.e., mitral regurgitation (MR).

Low-frequency phonocardiogram from a 15-year-old girl with severe rheumatic MR. Besides the loud MR murmur and S3, note the following: (1) The widely split S2 (A2-P2) expected if moderate to severe MR is present. (2) The P2 is well heard at the apex and should make you suspect some pulmonary hypertension. The patient's pulmonary artery systolic pressure was 35 mmHg (upper normal is 25 mmHg.)

Low-frequency phonocardiogram from a 15-year-old girl with severe rheumatic MR. Besides the loud MR murmur and S3, note the following: (1) The widely split S2 (A2-P2) expected if moderate to severe MR is present. (2) The P2 is well heard at the apex and should make you suspect some pulmonary hypertension. The patient's pulmonary artery systolic pressure was 35 mmHg (upper normal is 25 mmHg.)

Note: Excessive flow through a tricuspid valve does not usually cause a right-sided S3, i.e., there is no physiological right-sided S3. The right ventricular (RV] S3 requires not only a large RV but also a stiff RV and high right atrial pressure. For example, in an uncomplicated ASD with a very large flow through the tricuspid valve, there is usually no S3. It seems that the RV S3 occurs only when there is reduced compliance. The normal RV is more compliant than the LV and unless it becomes thick because it is also pressure-overloaded, it expands easily to accommodate increased flow.

2. How can the detection of an S3 tell you whether the pulmonary hypertension in a patient with a VSD or PDA is due to an increased flow (hyperkinetic) or to a fixed irreversible resistance?

ANS: The presence of a LV S3 signifies that there is increased flow through the mitral valve and, therefore, also through the pulmonary circuit. The pulmonary hypertension must, therefore, be hyperkinetic and not fixed. This means that surgical closure of the VSD or PDA may lower the pulmonary artery pressure to normal [3].

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