Download Grech - evaluation child with murmur

Evaluation of
the child
with a murmur
Dr. Victor Grech
Cons. Paed. (Cardiol)
Background
• Very vexing and recurring topic
• Murmurs are often noted in children
• When to refer/defer?
• The former safe - worries parents.
• The latter ? miss pathology
Background 2
• Murmurs routinely detected > 33% school-age.
• Especially pronounced during febrile illness.
• However
– Many (>30%) normal children have murmurs
– very few have heart disease (<1%)
How to decide?
• A good history and thorough examination!
• Ask specifically for
– FH CHD
– FH Marfan’s syndrome
– FH sudden death or cardiomyopathy.
• Symptoms and signs to look out for include chest pain and
SOB in older children (very rarely elicited complaints)
• Poor feeding + failure to thrive/cyanosis in early infancy.
Absent
radii
5
How to decide 2
• In the examination, look out for
– Increased precordial activity
– Thrills
– Poor or absent femoral pulses (? 1st)
– Liver (?1st)
– Hypertension
Four week old in HF
7
How to decide 3
• Presence or absence of a murmur, AND
– Abnormal .
– A fixed split second sound is indicative of an atrial septal defect or
some other form of shunting at atrial level.
– A loud and single second sound indicates pulmonary hypertension.
– Clicks in association with murmurs may indicate pulmonary or
aortic stenosis or mitral valve prolapse.
– Murmurs that are loud, harsh or diastolic are never physiological.
The age of onset of a murmur is
related to the likelihood of
pathology. For example:
Murmur onset at 24 hours of life
8% likelihood of being
pathological
Murmur onset at 6 months of life
14% likelihood of being
pathological
Murmur onset at 12 months of life
2% likelihood of being
pathological
Still’s murmur 1
• The most common type of innocent childhood
murmur is a Still’s murmur, first described by Sir.
George Still (England’s first professor of childhood
medicine) in 1909.
• Early and mid systolic, loudest at the lower left
sternal edge and is high pitched.
Still’s murmur 2
• George Frederic Still, M.D
– Common Disorders and Diseases of Childhood
– published in 1909
– “I should like to draw attention to a particular bruit which has somewhat of a
musical character, but is neither of sinister omen nor does it indicate
endocarditis of any sort. …its characteristic feature is a twangy sound, very
like that made by twanging a piece of tense string... Whenever may be its
origin, I think it is clearly functional, that is to say, not due to any organic
disease of the heart either congenital or acquired.”
11
Still’s 3
• Caused by intracardiac blood flow so accentuated by
conditions wherein cardiac output is increased, such
as febrile illnesses.
• Physiological - no antibiotic prophylaxis.
• Usually disappears in puberty.
• Does not need cardiology F/U
Venous hum
• Second commonest innocent murmur in childhood
• Low-pitched continuous rumble
• Louder in diastole, best heard at the right sternal
edge.
• SVC flow therefore disappears when the amount or
velocity of flow through this vessel is reduced.
• By
– Lying the child down in the supine position
– Turning the head to the left side
– Application of light hand pressure on the right jugular
vein.
Venous hum 2
NB - positional variation
• Still’s murmur ↑ lying down
• Venous hum
• @URSE - ↓:
– Child lying down or
– Light pressure over jugular vein or
– When the child's head is turned.
15
Pathological murmurs
Ventricular septal defect
Atrial septal defect
Pulmonary valve stenosis
Pulmonary artery stenosis
Aortic valve stenosis
Patent ductus arteriosus
Mitral valve prolapse
Others
38%
18%
13%
7%
4%
4%
4%
4%
Common pathology
• VSD
– Large defect - early Dx
with HF. ? Not PSM
– Small defect - ?late Dx
incidental finding-PSM
– Large - operation
– Small - just antibiotic
prophylaxis for
dental/surgical
17
Common pathology
• PDA
– Contin (machinery) murmur
– Large - HF as VSD
– Small as small VSD
– Large with HF in childhood
- surgical repair
– If not in HF: device closure
via catheter
18
Common pathology
• PS
– Click
– Widely split S2
– ESM
– Almost always
amenable to balloon
dilatation via catheter
19
Murmur most easily confused with a physiological
murmur is that caused by a left-to-right shunt at atrial
level, most commonly, a secundum atrial septal defect.
ASD
• Left-to-right shunting through ASD does
not in itself cause any murmurs, unlike for
example a ventricular septal defect.
• Murmur caused by xs flow across the PV.
• Fixed splitting of the second heart sound
ASD
– RV+
– Pulm syst flow
murmur ± diastolic
– Fixed split S2
– Cath device closure or
surgical repair at 4-5y
or if later, on
diagnosis
22
ASD
large heart
and
pulmonary
plethora
23
When in doubt, children with murmurs should be
referred for a paediatric cardiology evaluation that
may include an echocardiogram
ASD - echocardiogram
TOE before & after device closure
25
Other invest. modalities: MRI
• MRI of young lady
• Had coarctation repair
• Recoarctation
26
Endocarditis
• Fever.
• CHD – operated.
• Other stigmata.
• Not only CHD.
Prevention
• Dental care.
• Dental visits.
• ‘Green card’.