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Systolic sounds - mid to late systole

Mitral prolapse

• Generates systolic click(s) when the motion of a prolapsing anterior leaflet or posterior scallop is abruptly arrested by the chordae tendinae.
• Maneuvers that reduce left ventricular size (Valsalva, standing) move the click earlier into systole.
• Maneuvers that increase left ventricular size (squatting, hand grip) move the clicks later into systole.
• Tricuspid valve can also generate systolic sounds.

Pericardial sounds

• Occasionally occur in mid to late systole.