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©2013 UpToDate ® Email Phonocardiogram of aortic regurgitation as heard at the apex Carotid artery pulse tracing and phonocardiogram of aortic regurgitation as heard at the apex. There is a fourth heart sound (S4) heard prior to S1 (mitral and tricuspid valve closure) and the upstroke of the carotid arterial pulses. This is the result of atrial contraction into the "stiffened" left ventricle. Following S1 is a short systolic ejection murmur which results from the large stroke volume seen in aortic regurgitation. Provided by John M Criley, MD, The Physiological Origins of Heart Sounds and Murmurs, Little, Brown, Boston, 1996, 1-800-527-0145. This program contains a complete interactive tutorial integrating over 200 heart sounds and murmurs with cineangiographic, echo-Doppler, and hemodynamic motion picture sequences.