Systolic Ejection Click vs. Split First Heart Sound: Are Our Ears Deceiving Us? Open Access

Hoeting, Natalie Michelle-Lane (2017)

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Bicuspid aortic valve disease is associated with lifetime complications, but auscultation of this subtle pathology is commonly missed or mistaken for a benign split first heart sound. The authors sought to determine whether pediatric cardiologists could distinguish between bicuspid aortic valves and split first heart sounds.


Quality evaluation project using de-identified recordings from Sibley Heart Center clinic patients, Atlanta, GA.

Outcome Measures

21 cardiologists listened to 5 recordings of pediatric heart sounds and indicated whether each recording was a bicuspid valve or split heart sound. 3 had the systolic ejection click of bicuspid aortic valves, and 2 contained mitral components of split first heart sounds. We determined accuracy of diagnoses using percent agreement and calculated kappa coefficients for the cohort and subgroups based on those with <10 years of experience vs. those with ≥10 years. To access precision, we used a Kappa extension for multiple raters to assess interrater agreement among the 21 cardiologists.


Among participants, diagnostic accuracy of bicuspid aortic valves was 38%, while accuracy of split first heart sound was 41%. No participant correctly diagnosed all sounds. No difference in agreement was observed when stratifying by experience. Kappa was -0.11 (CI 95% -0.31-0.08) for all raters, -0.03 (CI 95% -0.39-0.33) for those with <10 years' experience, and -0.15 (CI 95% -0.38-0.08) for those with >10 years' experience. The Kappa statistic among the 21 raters was 0.01 (95% CI -0.03 - 0.04), indicating poor precision among the raters.


In this sample of pediatric cardiologists, the diagnostic accuracy of bicuspid atrial valves vs split first heart sounds was worse than chance. There was no association between years of experience and diagnostic accuracy. While further study is needed, these data suggest that an echocardiogram may be valuable when either a systolic ejection click or split first heart sound is heard.

Table of Contents

Table of Contents

Page #

Introduction 1

Methods 2-3

Results 4

Discussion 5-7

References 8-10

Tables 11

Figures 12

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