Palpation of diastolic motion of LV

Palpation of diastolic motion of left ventricle (LV)

All of us familiar with the systolic motion of the left ventricular apex which is palpated as the apex beat or apical impulse. Two diastolic movements may be palpable:

1. Diastolic filling of the left ventricle when it is rapid as in mitral regurgitation, dilated left ventricle or ventricle with impaired systolic function. This movement corresponds to and is the mechanical equivalent of third heart sound. This has been described as contributing to the occasional quadruple apical impulse in hypertrophic obstructive cardiomyopathy (HOCM) [1]. It may be noted in this context that triple apical impulse in HOCM is a combination of two systolic and one diastolic impulse due to atrial contraction. More common is a double apical impulse in HOCM which could be two systolic impulses or one systolic and one presystolic impulse.
2. A presystolic left  ventricular impulse may be felt in conditions with forceful atrial contraction and is the mechanical equivalent of fourth heart sound. This contributes to the triple apical impulse in HOCM as mentioned above. Presystolic impulse is an indicator of left ventricular diastolic dysfunction leading to forceful atrial contraction contributing to ventricular filling.

Both these pulsations are best appreciated in left lateral decubitus position with the breath held in expiration.

Reference

1. Howard S. Rosman. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Chapter 21 Precordial Impulses.