Physiology of the Third Heart Sound: Novel Insights from Tissue Doppler Imaging

Sanjiv J. Shah, Gregory M. Marcus, Ivor L. Gerber, Barry H. McKeown, Joshua C. Vessey, Mark V. Jordan, Michele Huddleston, Elyse Foster, Kanu Chatterjee, Andrew D. Michaels*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Background: The third heart sound (S3) is thought to be caused by the abrupt deceleration of left ventricular (LV) inflow during early diastole, increased LV filling pressures, and decreased LV compliance. We sought to determine whether the ratio of early mitral inflow velocity to diastolic velocity of the mitral annulus (E/E') could confirm the proposed mechanism of the S3. Methods: A total of 90 subjects underwent phonocardiography, echocardiography, tissue Doppler imaging, and left-sided heart catheterization. Results: Phonocardiography detected an S3 in 21 patients (23%). Subjects with an S3 had lower ejection fraction (P = .0006) and increased E deceleration rate (P < .0001), E/E' (P < .0001) and filling pressures (P < .0001). The phonocardiographic S3 confidence score correlated with E/E' (r = 0.46; P < .0001) and E deceleration rate (r = 0.43, P = .0001). Of the echocardiographic variables, only E/E' was independently associated with the S3 confidence score (P = .009), independently of invasively determined LV filling pressures (P = .001). Conclusions: The most important determinants of the pathologic S3 are an increased deceleration rate of early mitral inflow, elevated LV filling pressures, and abnormal compliance of the myocardium as measured by tissue Doppler imaging.

Original languageEnglish (US)
Pages (from-to)394-400
Number of pages7
JournalJournal of the American Society of Echocardiography
Issue number4
StatePublished - Apr 2008

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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