2Murmurs in ChildrenHeart murmurs are one of the most common physical findings in any practice that cares for children50-60% of children have a heart murmurOver 90% of heart murmurs are normal and require no further evaluation/referraltermed “innocent,” “functional,” “benign,” or “physiologic”
3Evaluation of MurmurTiming – where during cardiac cycle? – systolic, diastolic, or continuousType – holosystolic, ejection/crescendo-decrescendo, early, lateQuality – harsh, blowing, vibratoryIntensity – grades I-VI
4Innocent Murmurs Not solely diastolic! (systolic or continuous) Not associated with a thrill! (grades I-III)Not associated with a click!
5Grading Murmurs Grade Description I Barely audible II Easily audible IIIVery audible without a thrillIVWith thrill – stethoscope fully on chestVWith thrill – stethoscope halfway off chestVIWith thrill – stethoscope off chest
6Grading Murmurs – A New Approach GradeDescriptionILess in intensity to heart soundsIIEqual in intensity to heart soundsIIIGreater in intensity to heart sounds, without thrillIVWith thrill, stethoscope fully on chestVWith thrill, stethoscope halfway offVIWith thrill, stethoscope off chest
7Logic-based Pneumonic Innocent murmurs occur at sites with disproportionate-sized connectionsSmaller vessel connecting to larger vesselOr larger vessel branching into smaller vessels
81. Venous HumConnection between jugular, subclavian, and innominate veins to SVC
9Venous Hum Most common continuous murmur in children Most often in ages 2-8 y/o (toddlers to school-age)Low frequency, continuous murmur often louder in diastoleBest heard below the right clavicle
10Venous Hum Increased: in sitting or standing position Decreased: in supine position, with compression of neck veins (directly or with changes in head position)Compressing neck veins or turning head to the right will diminish murmurDiminishes completely in supine position
11Venous Hum – differential diagnosis PDA – loud, continuous machinery murmur with systolic prominencebest heard on left 2nd interspace and radiates to backnot changed with position or neck vein occlusionAV fistula – not changed with position or occlusion of neck veins
122. Pulmonary Flow MurmurConnection of right ventricle with main pulmonary artery
13Pulmonary Flow MurmurMay be heard in wide range from school-age children to adolescents and young adultsLow intensity systolic ejection murmurBest heard at LUSB (2nd or 3rd interspace)
14Pulmonary Flow MurmurIncreased: high output states (fever, illness, anemia, etc), with expirationDecreased: standing position, with inspiration
15Pulmonary Flow MurmurIs exaggerated by any condition that brings the RVOT closer to the anterior chest walleg. pectus excavatum, kyphoscoliosis
16Pulmonary Flow Murmur – differential diagnosis ASD – “relative” pulmonic stenosis murmur (due to increased blood volume in right heart)accompanied by a widely split S2, mid-diastolic flow murmur, right ventricular heavePulmonic stenosis – louder, harsher sounding murmurcan be associated with a thrill or ejection click
173. Physiologic Peripheral Pulmonary Stenosis (PPS) Connection of main pulmonary artery to right and left pulmonary artery branches
18Physiologic PPSMost often in neonates and infants from birth to 6 mos of ageSoft, low-pitched systolic ejection murmur (can extend slightly past S2)“blowing” in quality, sounds like breath sounds (can briefly occlude nares)Best heard at left infraclavicular area with radiation to bilateral axillae and back
19Physiologic PPSIncreased in: high output states (fever, illness, anemia, etc), viral URI, RAD exacerbations
20PPS – differential diagnosis Pulmonic stenosis – louder, harsher murmur, associated with ejection click or thrillVSD – no radiation to axillaePDA – machinery like, lower pitchPathologic PPS – longer duration, higher pitch, older children
214. Still’s MurmurConnection of left ventricle with aorta
22Still’s Murmur Most common innocent murmur in children Reported to be present in up to 75-85% of childrenMost often in ages 2-6 y/o, but can be from birth to adolescence
23Still’s Murmur Low-pitched II/VI early systolic ejection murmur Described as “vibratory,” “musical,” “harmonic,” “twanging,” “groaning/moaning,” “squeaky”Like the sound of a guitar string being pluckedBest heard at LLSB/apex
24Still’s Murmur Increased: supine position, fever, anemia Decreased: sitting or standing, with valsalva
25Still’s Murmur – differential diagnosis VSD – different quality, harsh not musicalLVOT obstruction – different qualityHOCM – different quality
265. Supraclavicular Systemic Bruit Connection of brachiocephalic vessels to aortic arch
27Supraclavicular Systemic Bruit Heard in children and young adultsHarsh, medium to high-pitched, brief early systolic ejection murmurBest heard in the carotids bilaterally with some radiation to infraclavicular area
28Supraclavicular Systemic Bruit Decreased: with shoulders pulled back (hyperextension)No change with position
29Supraclavicular Systemic Bruit – differential diagnosis Aortic stenosis/supraaortic stenosis – louder in chest with radiation to carotids
30ASD Most common misdiagnosed heart murmur in children More often than not there is no murmur heard with ASD
31Auscultation of ASD3 auscultatory findings in ASD – all due to L-to-R shunting across defect larger blood volume in right heart1. widely split S2 – longer time to empty right side of heart vs. left side2. pulmonary “stenosis” flow murmur – large amount of blood exiting through RVOT3. mid-diastolic flow murmur – large amount of flow across triscuspid valve
32Red Flags! – Caution! Holosystolic murmur Presence of a thrill (grade >III/VI)Harsh qualityPresence of early/mid systolic clickAbnormal S2Diastolic murmurIncrease in intensity with standing up
33Beware! General appearance – dysmorphic features Constitutional – poor weight gain, diaphoresis, cyanosisRespiratory symptoms – tachypnea, wheezing, chronic cough, poor/difficulty feedingCardiovascular symptoms – chest pain, syncope/presyncope, tachycardiaAbnormal tests – enlarged heart on CXR, hypertrophy on EKG
34Case 1A 5 y/o Latin American boy presents for his annual school physical. He has no significant PMH and is very active. More recently he has had fever and diarrhea. PE is normal with the exception of this murmur heard at the LLSB near the apex.You tell mom that he has a benign murmur. She asks you why no doctor has ever heard this murmur before today. You say?
35Case 1He has a vibratory Still’s murmur that is just now detected since he is sick with fever (high output state increases intensity of the murmur).
36Case 2You are a medical student and you are examining a 6 y/o Caucasian girl here for routine check-up. She is previously healthy and has no complaints. During PE, you listen to her heart as she lies on the exam table. You present her CV exam as normal to your attending. He examines her as she sits on the table and he hears this murmur just below her right clavicle.You are very embarrassed for missing this obvious murmur. What was your mistake?
37Case 2She has a venous hum murmur that diminishes completely in the supine position. It is important to perform the CV exam in both supine and upright positions.Your attending is not upset and tells you that you will not fail the cardiology elective afterall. PHEW!
38Case 33 y/o AA girl is a new patient who has a history of a heart murmur per mom. Mom says her previous pediatrician told her that the murmur was “harmless and normal.” You take a listen and hear this murmur at the LUSB.Do you refer her to a cardiologist? Why? Why not?
39Case 3She has a LUSB SEM associated with a abnormally split second heart sound which is indicative of an ASD.
40ReferencesSapin SO. Recognizing Normal Heart Murmurs: A Logic-based Pneumonic. Pediatrics 1997; 99(4):Biancaniello T. Innocent Murmurs. Circulation 2005; 111:e20-e22Poddar B, Basu S. Approach to a Child with a Heart Murmur. Indian J Pediatr 2004; 71(1):63-66Brumund MR, Strong WB. Murmurs, Fainting, Chest Pain: Time for a Cardiology Referral? Contemporary Pediatrics 2002;Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for Grading Heart Murmur Intensity [abstract]. Arch Pediatr Adolesc Med 2005; 159(4):329-34Moses S.