Pathophysiology
Valvular ES: Vibrations in  Stenotic aortic or paulmonic valves will cause the ejection sounds. The condition is that the valve is compliant and mobile as in congenital bicuspid valves and in the early stages of calcified valves. As calcifications becomes more severe, the valves becomes less mobile and the ejection sound will disappear. In a normal valve, the leaflets do not resist in the opening motions and no sound is heard. In a stenotic, but mobile valve, the valve will resist the pressure and when forced open the vibrations are created.

Vascular ES: In dilatation of the aortic root or the pulmonary artery the ejection sounds are created by sudden “checking” of the walls of the aorta or the pulmonary artery, initiated by forceful impact of blood against these structures.