In a 5 year old child, instead of the physiological splitting of second hea sound which is expected only during inspiration, a wide and a fixed split of S2 is heard during both inspiration as well as expiration. Wide fixed split of second hea sound can be seen in all of the following EXCEPT?

**Core Concept**
The physiological splitting of the second heart sound (S2) is due to the slight delay between the closure of the aortic and pulmonary valves, which is normally more pronounced during inspiration due to increased venous return to the right heart. This phenomenon is a result of the **respiratory variation in intrathoracic pressure** affecting the timing of valve closure.

**Why the Correct Answer is Right**
A wide and fixed split of S2, heard during both inspiration and expiration, suggests an abnormality in the timing of valve closure, often due to conditions affecting the **pulmonary outflow tract** or **right ventricular ejection**. This can be seen in conditions such as atrial septal defects (ASDs), which increase flow through the pulmonary valve, delaying its closure.

**Why Each Wrong Option is Incorrect**
**Option A:** Atrial septal defect (ASD) is a correct association with a wide fixed split S2 due to increased flow through the pulmonary valve.
**Option B:** Ventricular septal defect (VSD) can also cause increased flow through the pulmonary valve, although the effect on S2 splitting may vary.
**Option C:** Pulmonary stenosis can affect the timing of pulmonary valve closure, potentially leading to a wide fixed split S2.

**Clinical Pearl / High-Yield Fact**
A wide fixed split of the second heart sound is a key finding in **atrial septal defects**, and its presence during both inspiration and expiration is a significant clue to this diagnosis.

**Correct Answer:** D.

✓ Correct Answer: B. Ventricular septal defect