A 69 year old woman with hypertensive heart disease had a loud added sound which coincided with a sudden interruption of the early diastolic motion of the left ventricular posterior wall, as visualised by M mode echocardiography, and came just before early diastolic transmitral flow, as measured by a pulsed Doppler echocardiogram. Early diastolic motion velocity from the base to the middle of the posterior wall, assessed by pulsed Doppler tissue imaging, was markedly high and sharp, and its peak coincided with the sound. A notch, similar to that in the posterior wall motion, occurred in the left ventricular pressure curve during early diastole. No intraventricular flow signal was detected during the isovolumic relaxation period, as measured by pulsed and colour Doppler imaging. The added sound was probably produced by impact between the dilated heart, with a relaxation abnormality, and the extracardiac structures during the isovolumic relaxation period.
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