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S1: closure of mitral and tricuspid valves. S2: closure of aortic and pulmonary artery valves. S2 may be split with normal inspiration (aortic valve closes first), RBBB, pulmonary embolism. A paradoxical split is when the aortic closes after the pulmonic valve, as can occur in LBBB, pacemaker, LV dysfunction. A fixed split can occur in atrial septal defect. First Aid for the Family Medicine Boards b    (retrieved Feb, 2014). There are currently 1090 pearls in the database. While every attempt has been made to ensure accuracy, mistakes can and do occur. Use databank at your own risk. All pearls © 2024 by the Internet Medical Association. Click Here to view more medical pearls.