Posts Tagged ‘heart sounds’

Third heart sound is a unique heart sound  because its   perfect physiology  to hear it  in the young  ,  while the same may denote  serious LV dysfunction in patients with myocardial disease.

It is a low pitched  early diastolic sound usually correspond to  the end of rapid filling phase.The mechanism of genesis of this sound has been debated for many years .(Still I think it is unsettled !)

We know genesis of intracardiac sound is contributed  by three factors

  • The blood flow
  • The valve motion
  • The myocardial contractile and  relaxyl  property

The above  three is collectively  called cardio-hemic system . When this system vibrates heart sounds are generated .In  the genesis of S3 all the three may be important . The only difference is ,  in physiological S3 the valvular and hemic component play a major role . In pathological S3 the  myocardial component has a pivotal  role .The distended LV facilitates chest wall impact during the rapid filling phase . It is now  accepted  LV S3 is  generated outside the LV  . It  was proved elegantly by Shaver et all with sound recording on either side of  LV /Chest wall.

It is to be emphasized  the mechanism of genesis of S3 is diagonally opposite in  physiology vs  pathological  S3 in some conditions . Rapid AV filling  can  rarely be  responsible for pathological  S3  associated with severe LV dysfunction , while chest wall  impact can contribute in both physiological as well as pathological S 3 .

 One can understand the complexity of genesis of  S 3  , as  there are  too many  determinants  that contribute in  varying degree of acoustics.

Factors determining the intensity of S3 is complex 

  1. Age,
  2. Atrial pressure,
  3. Rapidity of  flow across the atrio-ventricular valve,
  4.  Rate of early  diastolic relaxation 
  5.  Distensibility of the ventricle,
  6.  Blood  volume,
  7. Ventricular cavity size,
  8.  Diastolic momentum of the  heart,
  9. Degree of contact (coupling) with the chest wall, thickness
  10. Character of the chest wall
  11.  The position of the  patient.


It is ironical, pathological   S3 which is a  diastolic  sound  though ,  still  its genesis  is largely  determined by the systolic function of the heart .This mystery is partially solved as we recognise  now ,  LV S3 is equally common in  severe degrees of diastolic dysfunction. In fact ,  while we were studying the relationship  of LVS3 in DCM  , it  has strongly predicted the  presence of   severe restrictive pattern in them .




1.Multimedia of S3


2.Importance of  S3 in cardiology NEJM 2001 article


3.Chest wall impact theory of S3  by Shaver

Shaver JA, Salerni R. Auscultation of the heart. In: Hurst, ed. Heart. 8th ed. New York, NY: McGraw-Hill, Inc; 1994:291.

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Cannon Sound

A loud first heart sound (S 1)   which is  heard intermittently in patients with complete heart block (CHB)  is  often referred to as  cannon sound .

What is the mechanism of loud S1 in CHB ?

We know , the intensity of S 1 is  mainly determined by the  relative position of mitral leaflet (To be precise, the  anterior mitral leaflet(AML) )   at the onset of systole.  We also know the  PR interval  has an intricate relationship to  mitral leaflet  position .

The shorter it is ,  wider the leaflet separation  and a longer PR interval makes a mitral leaflet assume a almost closed position   by the time the ventricle contracts.this happens because  a long drawn PR interval fills the ventricle more completely and LVEDV  reaches the maximal levels and LV blood column lifts up the mitral leaflets , and hence the LV  contraction  which follows does not close it with a  bang. In a short PR interval the opposite happens and hence a loud S1 .

In CHB we have variety of PR intervals ranging between  very short to long   ( falling just before the qrs complex) It is not difficult to understand this , as P waves are totally dissociated with the QRS complex  in CHB.In fact p waves have a liberty to fall any where in the ECG tracing , some call this as marching through the qrs complex !.

Hence typically the S1 is variable in intensity , varying between loud to soft.  When  P wave falls just behind a QRS complex , it generates a very  loud S 1  that is called cannon sound .This happens intermittently.

Cannon wave

This is entirely different phenomenon except that it shares the word cannon . Cannon a wave is  a visual finding on the jugular venous pulse.(JVP) .It is a systolic event . It is also seen in CHB as like a cannon sound

This is a giant a wave  in  JVP  when the right atrium contracts against a closed tricuspid valve. In physiological situations atrium contracts with an open AV valves , so that ventricle gets  filled . So atrial contraction  does not does not cause any reflux of blood back into vena cava.

But, when the atrium  contracts and  finds , the AV valve closed  there is no other option   for the incoming blood  to reflux  back into  the neck veins. This is seen as giant a waves called as cannon ” a “waves

With reference to ECG  location ,  this cannon”  a” wave occurs   whenever p wave falls within the ventricular systole ie  the QT interval .The cannon waves also occur intermittently like the  cannon sounds.

What is the  peculiar relationship between cannon a wave and   sound ?

In fact , it is  a non- relationship.  Though  , both the sound and wave   can occur in a given  patient with CHB ,   they can not occur simultaneously .This is because ,  for cannon sounds   to occur  the  P  wave has to fall before  QRS  and for cannon waves to occur the  p   waves must fall after QRS  ie with QT interval .

Clinical significance  of  cannon wave

Complete heart block is the most common situation for cannon waves to occur.

Ironically ,the VVI pacemaker which is used  to treat CHB does not prevent the cannon waves , and atrial contractions continue to occur at random , causing various degrees of intermittent venous reflux into the veins .This may produce, worrisome venous palpitation in some (Usually settles down after few weeks !)

Some attribute , the so called pacemaker syndrome ie giddiness, dizziness to this abnormal venous waves triggering the carotid baroreceptors (Venous -artery spillover )

Will DDD pacemakers  eliminate venous cannon waves ?

We hoped so , it does in fact . But,  it really happens only if the A sense V pace mode . A pace V pace mode with programmed PR interval is not a realiable way to produce AV synchrony. It is  common ,  many of the DDD pacemakers fall back to VVI mode either intentionally or by mode switching  for various reasons.


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