You are incorrect - our patient's second heart sound at the upper left sternal edge is split in inspiration with the second component, P2, louder than the first component, A2.


Your choice: Paradoxic splitting
Click the play button to complete this section. To view any topic, select the button below.



Paradoxic splitting Graphis
This is a graphic example of paradoxic splitting of S2. Note that splitting of the second heart sound is best heard at the upper left sternal edge.

Discussion
One type of expiratory splitting is paradoxical splitting of the second heart sound. It occurs whenever the aortic closure sound is significantly delayed. During inspiration, the sounds fuse, as P2 is also delayed. During expiration, pulmonary closure precedes the delayed A2. Causes of paradoxical splitting include electrical and mechanical delayes such as left bundle branch block and aortic stenosis.