Aortic ejection.
The patient below has right bundle branch block, mitral insufficiency, aortic stenosis and tricuspid insufficiency.
Continuous wave Doppler flow shows onset of the aortic ejection flow on the S wave of the QRS. The mitral insufficiency flow begins earlier - during the isovolumic period and lasts longer than the aortic ejection. These flow patterns on the left side of the heart would also be present in patients with a normal QRS duration, and are unaffected by the the delay in right ventricular depolarization in this patient.
Doppler is also useful in demonstrating the timing of mitral and tricuspid valve closure in relation to the QRS complex. It can therefore be used to demonstrate the change in timing of right sided events in right bundle branch block.
Although tricuspid insufficiency flow starts during the isovolumic period, the actual closure Doppler signal of the tricuspid valve is delayed due to the right bundle branch block.
Using the QRS for reference it is clear in the images below that the tricuspid valve Doppler closure signal is delayed when compared to time of mitral valve closure (in the image above it).
On auscultation in right bundle branch block, the first heart sound may become audibly reduplicated (split) because of this increased time delay between mitral and tricuspid valve closure.
Aortic ejection.
Mitral insufficiency.
Tricuspid insufficiency.
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