**4.1 AS in the pediatric patient**

Most children with valvar AS are asymptomatic and the AS is usually detected because of a cardiac murmur heard on routine auscultation [15–17]. Patients with severe AS may exhibit symptoms such as dyspnea, easy fatigability, or chest pain. Syncope may be a presenting complaint in some children with very severe AS. On physical examination, the left ventricular impulse is increased (left ventricular heave) in all but mild cases. A thrill may be felt at the right upper sternal border and/or in the supra-sternal notch. The first heart sound is usually normal. The second heart sound is also normal unless the AS is extremely severe when there may be a paradoxical splitting of the second heart sound. An ejection systolic click is heard best at the apex and left mid and right upper sternal borders and the click does not vary with respiration. An ejection systolic murmur of grade II–V/VI intensity is heard best at the right upper sternal border with radiation into both carotid arteries. The arterial pulses are usually normal.
