1. Innocent Systolic Murmur Chapter 13
Are G. Talking, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS

2. Outline Characteristics of an Innocent Murmur
Characteristics of a Pathological Murmur
Where Systolic Murmurs May be Produced
Classification
Still’s Vibratory Systolic Murmur
Physiological Pulmonary Ejection Murmur
Supraclavicular Arterial Bruit, Venous Hum
Peripheral Pulmonary Stenosis of the Newborn
Innocent Aortic Systolic Murmur
Mammary Arterial Souffle
Straight-Back Syndrome & Pectus Excavatum

3. Characteristic of An Innocent Murmur
Short (early to mid-systolic, except for the venous hum
Low to medium pitch
Possibly a musical component
Normal physiological splitting of S2
Commonly found in children & early teen year
Isolated systolic murmurs in the elderly are common & are frequently innocent

4. Characteristics of A Pathological Murmur
Six Cardinal Clinical Signs
Holosystolic Murmur
Harsh Murmur
Abnormal heart sound
Early or mid-systolic click
Grade III murmur or greater
Heard over the upper left sternal border

5. Where Systolic Murmurs May Be Produced
Connection of the jugular, subclavian, & innominate veins to SVC (venonus hum; supraclavicular spaces)
Connection of RV to MPA (Pulmonary flow murmur; left sternal border, 2nd 3rd intercostal spaces)
Connection of the MPA to the RT & LT PA branches (peripheral PS of the newborn; upper sternal border)
Connection of the LV to the AO (Still’s murmur; apex)
Connection of the Aortic Arch to the brachiocephalic vessels (supra-clavicular arterial bruit; supracalvicular fossa)

6. Classification Five types of innocent murmurs heard in childhood:
Still’s murmur or vibratory systolic murmur
Physiological or functional pulmonary ejection murmur
Supraclavicular arterial bruit
Venous hum
Peripheral Pulmonary stenosis of the newborn

8. Still’s Vibratory Systolic Murmur
Peak incidence in children 3 to 7 years, disappears at puberty
Musical, vibratory, low-frequency, early systolic ejection murmur
George F. Stills in 1909
“A twanging sound”
Turbulence produced by the physiological narrowing of the LV outflow tract
Listen with the bell of the stethoscope over the lower mid-precordium or left lower sternal border & across to the apex
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10. Physiological Pulmonary Ejection Murmur
Early systolic, crescendo-decrescendo, mid-frequency, grade II
Decreases during inspiration when a child sits
Turbulent flow at the origin of the RT & LT pulmonary arteries
Listen with the diaphragm of the stethoscope along the left sternal border in the 2nd to 3rd intercostal space in supine position
Heard best during inspiration

12. Supraclavicular Arterial Bruit
Low to medium pitched, short, systolic, crescendo-decrescendo murmur
Unaffected by respiration; Grade II or Grade III
Heard at any age mid-childhood & in 30% to 40% of young adults
Common in high-output conditions; anemia & anxiety; prominent in trained athletes with slow heart rates & high stroke volume
Turbulence in the brachiocephalic or carotid arteries at their branching from the aorta
Listen with the bell of the stethoscope over the supraclavicular fossa and over the sternomastoid muscle with patient sitting

13. Venous Hum
Blowing & Continuous extracardiac murmur that is loudest during diastole
Whining, roaring, or whirring; intensity varies form faint to grade VI
Louder under the inner edge of the right clavicle but extends form the supraclavicular area over the right internal jugular vein to the base of the heart
Thrill is often present in children with venous hum
Causes result form turbulent blood flow caused by two streams of blood entering the SVC
Listen with the bell of the stethoscope in the right supraclavicular space

15. Peripheral Pulmonary Stenosis of the Newborn
Short mid-systolic ejection murmur of medium pitch & intensity is best heard in the second intercostal space at the left sternal border
Result of the turbulence caused when the MPA is bigger or dilated than its branches
Heard in newborns and premature infants
Listen with the bell of the stethoscope during systole at the upper left sternal border & axillary areas

18. Innocent Aortic Systolic Murmur
Short, crescendo-decrescendo, low to medium pitch
Children, systolic flow murmurs may be secondary to any condition with increased systemic cardiac output
Listen with the bell of the stethoscope over the aortic area

19. Mammary Arterial Souffle
Described by Van Den Bergh in 1908
A medium to high-pitched murmur, arising in systole & possibly continuing into diastole
Listen with the diaphragm of the stethoscope on the anterior chest wall over the breast

21. Straight-Back Syndrome & Pectus Excavatum
Decrease of the anteroposterior diameter of the chest because of the loss of the normal degree of kyphosis of the upper thoracic spine, straight-back syndrome or because of the inward cavitation of the sternum at the anterior chest wall
Pulmonary systolic ejection murmur
Exaggerated inspiratory splitting of S2
X-ray revealing displacement of the heart to the left, apparent cardiomegaly, pancake heart

23. THE END OF CHAPTER 13
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp