About Video

This video clip recording is taken from a patient with aortic stenosis. In the simultaneously recorded audio, one can hear the ejection systolic murmur ending with a pause before the S2. The patient's head is towards the top of the field on the screen. The examiner is holding a tongue blade covered by a black tape, over the area of the apical impulse to demonstrate, its movement and its contour. The patient's heart rhythm is slightly irregular and careful observation will reveal that the irregularity is due to a premature beat following two or three regular sinus beats. The movement of the apical impulse is seen somewhat exaggerated visually by the tongue blade. The contour during the regular beats shows that the apical impulse seems to come out with a slight hesitation or a jerky step. In other words it seems to have a step initially on the outward movement followed by further movement reaching its peak. This is very characteristic of an atrial kick. The latter results from a strong left atrial contraction evoked by the decreased left ventricular compliance. It also means that the patient is in sinus rhythm and that there is no obstruction to mitral inflow (no mitral stenosis).In the second clip of the video from the same patient, the examiner demonstrates the apical impulse as seen by the movement of the chest wall where a small white tape has been placed. The apical impulse is defined as the lateral most impulse palpable over the precordium. It is important to be able to see and feel the movement of the chest wall underneath it so that one does not misinterpret a palpable shock of a loud first heart sound for the apex beat. A loud first heart sound may be palpable but one cannot locate it since it is not a movement of the chest wall. The apical impulse on the other hand causes essentially both a visible and a palpable movement of the chest wall. The visible area of the movement in this video clip of this patient appears to be not more than the size of a quarter (normal apex beat has an area of 2 cm x 2 cm or the size of a quarter). One can also palpate and express the extent of the area of the apical impulse in the traditional x axis (horizontal) and y axis (vertical) directions. Normally, in the x axis direction, it covers no more than two finger tips and in the y axis, it does not extend beyond one intercostal space. In the last video strip of the same patient, the examiner has placed two tongue blades (both covered by black tapes), one over the apex beat itself and the other slightly medial to it. This is to demonstrate the medial retraction that is very characteristic of the apical impulse formed by the left ventricle. One can easily observe that the tongue blade placed over the apex beat comes out with each systole, while at the same time the tongue blade which is medial to it shows an inward movement thereby showing that the underlying chest wall is retracting. This retraction medial to the apical impulse confirms that the apical impulse in this patient is formed by the left ventricle.