1. Heart sounds and intra- cardiac pressures.

2. Heart sounds: S1: Due to closure of mitral and tricuspid valves. S1: Due to closure of mitral and tricuspid valves. Softer: Cardiac failure, pericardial effusion, valvular incompetence Softer: Cardiac failure, pericardial effusion, valvular incompetence Louder: Tachycardia, shortened PR- interval, mitral stenosis with still pliable valve Louder: Tachycardia, shortened PR- interval, mitral stenosis with still pliable valve

3. S2: Closure of aortic and pulmonary valves. S2: Closure of aortic and pulmonary valves. Louder: Systemic and/or pulmonary HT Louder: Systemic and/or pulmonary HT Softer: Pericardial effusion, hypotension, valvular incompetence Softer: Pericardial effusion, hypotension, valvular incompetence

4. Splitting of S1 and S2: Normally: Deep inspiration, RV-filling, split S1: Tricuspid valve closes after mitral valve. Physiologicl splitting of S1. Normally: Deep inspiration, RV-filling, split S1: Tricuspid valve closes after mitral valve. Physiologicl splitting of S1. ASD: Fixed splitting of S1 ASD: Fixed splitting of S1 Electrical disturbances: RBBB, LBBB Electrical disturbances: RBBB, LBBB

5. Splitting of S2: Any condition(s) impairing emptying of LV or RV. Any condition(s) impairing emptying of LV or RV. Valvular stenosis, pulmonary HT etc Valvular stenosis, pulmonary HT etc

6. S3: Caused by rapid ventricular filling Caused by rapid ventricular filling Can be normal in the young Can be normal in the young Pathology: Pathology: Valvular incompetence Valvular incompetence

7. S4: Caused by stiff ventricle Caused by stiff ventricle During atrial contraction During atrial contraction AF: S4 ? or not AF: S4 ? or not

8. Intra-cardiac pressures: Intra-atrial pressure: RA: a,c,v waves on flebogram: From negative to +8 mmHg Intra-atrial pressure: RA: a,c,v waves on flebogram: From negative to +8 mmHg LA: Also a,c,v waves: Maximum +12 mmHg: Measured by catheter: Swan-Ganz LA: Also a,c,v waves: Maximum +12 mmHg: Measured by catheter: Swan-Ganz Pulmonary capillary wedge pressure: Pulmonary capillary wedge pressure:

9. Clinical application of wedge pressure: Pulmonary edema: Cardiac vs non-cardiac Pulmonary edema: Cardiac vs non-cardiac Increased wedge pressure=cardiac origin: Increased wedge pressure=cardiac origin: LV-failure or mitral valve: stenosis or acute incompetence LV-failure or mitral valve: stenosis or acute incompetence LV-failure: Systolic vs diastolic LV-failure: Systolic vs diastolic

10. Intra-ventricular pressures: RV: From 0 to 25 mmHg RV: From 0 to 25 mmHg LV: From 0 to 125 mmHg LV: From 0 to 125 mmHg

11. LV pressure-volume curve LV pressure-volume curve Diagram on cardiac cycle Diagram on cardiac cycle La Place`s law La Place`s law Poiseulle`s law Poiseulle`s law Study from textbook: Ganong Study from textbook: Ganong