Implications of Third Heart Sounds in Patients with Valvular Heart Disease

Abstract

The presence of third heart sounds in patients with valvular heart disease is often regarded as a sign of heart failure, but it may also depend on the type of valvular disease. We assessed the prevalence of third heart sounds and the relation between third heart sounds and cardiac function in 1281 patients with six types of valvular heart disease. The prevalence of third heart sounds was higher in patients with mitral regurgitation (46 percent) or aortic regurgitation (28 percent) than in those with aortic stenosis (11 percent) or mitral stenosis (8 percent). The left ventricular ejection fraction was significantly lower (P<0.001) when a third heart sound was detected in patients with aortic stenosis (0.38, vs. 0.56 in those without third heart sounds) or mixed aortic valve disease (0.40 vs. 0.55). However, the ejection fraction was only slightly lower in patients with mitral regurgitation and third heart sounds (0.51 vs. 0.57, P = 0.03). The pulmonary-capillary wedge pressure was higher (P<0.001) when a third heart sound was detected in patients with aortic stenosis (18.6 mm Hg, vs. 12.1 mm Hg in those without third heart sounds). There was no association between the wedge pressure and third heart sounds in patients with mitral regurgitation. The prevalence of third heart sounds increased with the severity of mitral regurgitation. In patients with mitral regurgitation, third heart sounds are common but do not necessarily reflect left ventricular systolic dysfunction or increased filling pressure. In patients with aortic stenosis, third heart sounds are uncommon but usually indicate the presence of systolic dysfunction and elevated filling pressure. (N Engl J Med 1992;327:458–62.), A THIRD heart sound or S3 gallop (previously known as a ventricular or protodiastolic gallop) in an adult is usually interpreted as a sign of ventricular dysfunction. Its detection depends on the skill of the examiner and varies widely even among experienced physicians.1 Nevertheless, it is useful in guiding therapy2 for patients with heart disease and assessing their prognosis.3 It has been associated with clinical heart failure,4 elevated atrial pressure,2,3 and abnormal ventricular function567 in a variety of conditions. S3 may arise from either the left or right ventricle and coincides with the rapid inflow of blood during… © 1992, Massachusetts Medical Society. All rights reserved.