Clinical evaluation in localizing level of obstruction to outflow from left ventricle: Importance of early systolic ejection click

Abstract

Numerous reports have stated that clinical examination may be unreliable in identifying the level of obstruction in patients with obstruction to outflow from the left ventricle. In this report we have stressed the usefulness and importance of the routine clinical evaluation, with particular emphasis on the audible early systolic ejection click, in determining the level of left ventricular outflow obstruction. Forty-seven patients with congenital valvular aortic stenosis, supravalvular aortic stenosis, discrete subvalvular stenosis, muscular subvalvular stenosis and combinations of these proved by direct observation in all but 3 patients were evaluated. Since 1960, when physicians have listened for the early systolic ejection click specifically, it has been present in 13 of 13 patients with congenital valvular aortic stenosis; it was not heard in any of the remaining patients with obstruction at other levels. In many instances there was little difference in the clinical findings between subjects with valvular and those with discrete subvalvular aortic obstruction except for the ejection click. With increasing experience, it is suggested that in some cases the clinical evaluation will be sufficient for localizing the level of outflow obstruction from the left ventricle, and thus, in selected cases, catheterization may be unnecessary prior to corrective surgery.