A sustained lower left sternal edge impulse with a presystolic and an early diastolic component may be felt in a patient with a poorly compliant, dilated right ventricle. The presystolic component is the palpable equivalent of an audible fourth heart sound, while the early diastolic component is the palpable equivalent of an audible third heart sound. In the video, note the presystolic component occurs just before the carotid pulse, the sustained impulse occurs with the carotid pulse and the early diastolic impulse occurs just after.