Download Definition: An extra abnormal heart sound usually detected while

4/19/2012
HEART MURMURS
THROUGHOUT
CHILDHOOD
Frances R. Zappalla, D.O.
Nemours Cardiac Center
A.I. du Pont Hospital for Children
Wilmington, DE
HEART MURMURS
Definition:
An extra abnormal heart sound
usually detected while listening to
the heartbeat with a stethoscope.
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PARENTAL ANXIETY…….
• Anxiety about need for medication (49%)
• Sports restrictions (41%)
• Cardiac surgery (29%),
• Cardiac risk for siblings (20%)
• Premature death (13%).
• 19% of mothers felt the murmur resulted from
something they did wrong during pregnancy.
• After reassurance from the cardiologist, 7% of parents
had persistent anxiety
J Pediatr. 2002 Jun;140(6):747-52
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HEART MURMURS
• Most systolic murmurs in otherwise healthy
children are innocent and do not need a
referral………...however, see the previous slide.
• If findings are suspicious or in the present of
parental anxiety…. referral for a cardiology office
visit is more cost effective than ordering an
echocardiogram alone
ECHO ONLY…
• Slightly more than half of echocardiography studies (68%)
•
performed in adult laboratories were technically adequate
• Of those 52% had the correct diagnosis
• 16% incorrect diagnosis
Repeat echocardiography in 38%
• Abnormalities not diagnosed correctly in 14%
• 6 had important lesions
• Normal hearts were labeled as abnormal in 18%
RA Hurwitz et al Peds 1998
DIASTOLIC MURMURS ARE
PATHOLOGIC UNTIL PROVEN
OTHERWISE
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AUSCULTATION AREAS
• RUSB – Aortic
• LUSB – Pulmonic
• LLSB – TV, Septum
• Apex - MV
Fetal
Circulation
The colors
indicate
the oxygen
saturation
of the blood.
The arrows show
the course of the
fetal circulation.
FETAL CIRCULATION
•
55 % of the highly saturated umbilical venous returns via
ductus venous to IVC - RA junction
• preferentially crosses the foramen ovale into the left
atrium
• Highest oxygen content diverted to coronary
arteries and the brain
•
Remaining umbilical venous flow, portal venous blood, and
SVC flow crosses the tricuspid valve
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Circulation
after Birth
Arrows
indicate the
course of the
neonatal
circulation.
TRANSITIONAL CIRCULATION
• Clamping of Umbilical cord
• Removes the low resistance placenta
• Decreases ductus venous flow and systemic venous
return to IVC
• Increases systemic resistance
• Spontaneous respiration
• Decreases pulmonary vascular resistance
• Increases pulmonary venous return to LA
TRANSITIONAL CIRCULATION
• Increased pulmonary venous return
• Increases in LA pressure
• Flap valve of foramen ovale closes
• PDA closes within 10 to 15 hours
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PULSE OXIMETRY
• 20,055 newborn babies were screened
• 53 had major congenital heart disease (24 critical)
• Prevalence of 2·6 per 1000 livebirths.
• Sensitivity of pulse oximetry 75·00% (95% CI) for critical cases
• 49·06% for all major congenital heart defects.
• False-positive results noted for 169 (0·8%)
• 6 cases were significant, but not major, CHD
• 40 were other illnesses that required urgent medical intervention.
• The prevalence of major CHDs with normal pulse oximetry was 1.4 per
1000 live births
• Ewer et al LANCET 2011
NEONATES AND INFANTS
LOW-RISK GROUP
• Otherwise well - no symptoms and no other signs
• Alert, active, feeding well, gaining weight
• Normal pulses, heart rate, respiratory rate and liver
size.
• Normal blood pressures in all extremities
• Normal pulse oximeter saturation in upper and lower
extremities in room air
NEONATES AND INFANTS
RED FLAGS
• Comfortable Tachypnea
• Diminished pulses
• Poor feeding
• Poor weight gain
• Pulse Oximetry <90%
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BENIGN MURMURS
IN THE NEONATE
• Physiologic peripheral pulmonary stenosis
• Transient patent ductus arteriosus murmur
• Tricuspid regurgitation murmur
• Flow Murmurs
PERIPHERAL PULMONARY STENOSIS
• Physiologic
• Grade 1-2/6 systolic ejection murmur
• Heard best in the upper left sternal border but
radiates well to the axilla and back
• Most resolved within 6 weeks
• Remainder by 6 months
TRANSIENT PATENT DUCTUS
ARTERIOSUS
• Closing ductus arteriosus
• Usually a systolic ejection murmur of 1-2/6 intensity
• Heard best in the left upper sternal border
• Usually heard at 24-48 hours of life and….. usually
has disappears by the time the cardiologist comes to
listen
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TRICUSPID REGURGITATION MURMUR
• Infants with fetal distress or perinatal asphyxia
• Holosystolic murmur due to high right
ventricular systolic pressure
• Sounds like a small ventricular septal defect
PATENT FORAMEN OVALE
• Normal structure
• Functional closure
• occurs after birth as left atrial pressure
exceeds right atrial pressure
• Right to left shunting
• may occur in neonatal period causing
peri-oral cyanosis
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PATHOLOGICAL MURMURS
• Most Common
• Ventricular septal defect
• Pulmonary stenosis
• Aortic stenosis
PATHOLOGICAL MURMURS
• AV valve insufficiency in Complete AV Canal
defect
• Tetralogy of Fallot
• Coarctation of the aorta
• Ebstein’s Anomaly
CHD WITHOUT MURMURS
• Hypoplastic left heart syndrome
• Tricuspid Atresia
• Critical Coarctation
• Interrupted aortic arch
• Complete Common AV canal
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APPROACH TO THE
CYANOTIC CHILD
• Pre- and post-ductal saturations
• measured on right arm and either leg
• detects shunting across the ductus arteriosus
• Arterial Blood Gas(es)
• Chest X-ray
• 12-lead ECG
APPROACH TO THE CYANOTIC CHILD
• Hyperoxia test:
• Document PaO2 in room air
• Administer 100% FiO2 for 10 minutes
• Repeat PaO2
in 100 % O2
PaO2 > 300 suggests
intrapulmonary shunt
PaO2 < 150 suggests
intracardiac shunt
APPROACH TO THE CYANOTIC NEONATE
Suspected Congenital Heart Disease
• Referral for pediatric cardiology evaluation
•
•
•
in-house consult
transport to tertiary center
Telemedicine
• Echocardiography for detailed anatomic diagnosis
• Medical management and surgical strategies based on
anatomic diagnosis
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VENTRICULAR SEPTAL DEFECTS
• Most common form of CHD
• 1.5 to 3.5 per 1000 term infants
• Slightly more common in females
• Most common defect in chromosomal syndromes
however……
• 95% of VSD not associated with chromosomal anomaly
LOCATION OF VSD
Perimembranous - most common (80%)
Muscular (5-20%)
PV
Subpulmonary
TV
Subaortic
Anterior
Inlet – AV canal type VSD (5-8%)
Apex
VENTRICULAR SEPTAL DEFECT
• Small ventricular septal defects
• Large ventricular septal defect
• NO murmur until pulmonary vascular
resistance drops
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AORTIC AND PULMONARY STENOSIS
• Murmurs may be heard soon after birth and
persist
• Usually preceded by an ejection click
• Constant with aortic stenosis
• Louder during expiration with pulmonic
stenosis
PULMONARY VALVE STENOSIS
• Usually asymptomatic
• Variable systolic ejection click at LUSB
• Grade 2-5/6 SEM at LUSB to lung fields
• Soft, delayed pulmonary component of S2
• May have increased RV impulse and thrill
• ECG: RVH
BALLOON
VALVULOPLASTY
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BENIGN MURMURS IN CHILDREN
• Stills Murmur
• Venous Hum
• Pulmonary Flow Murmur
STILL'S MURMUR
• Grade 1-2/6, musical or vibratory in nature
• Heard best at the lower left sternal border
• Murmurs are accentuated by
• anemia
• fever
• increased cardiac output
VENOUS HUM
• Varies with neck position and compression
• Diff Dx of Continuous murmurs :
•PDA, shunt, AV fistula
S1
S2
S1
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PATHOLOGIC HEART MURMURS
IN THE ADOLESCENT
• Atrial Septal Defects (ASD)
• Mitral valve prolapse (MVP)
• Hypertrophic Cardiomyopathy (HCM)
• Rheumatic heart disease (RHD)
ATRIAL SEPTAL DEFECTS
SVC
Secundum ASD and
PFO
Sinus Venosus ASD
Primum ASD
IVC
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ASD
PULMONARY FLOW MURMUR
•
Systolic flow murmur
•
Systolic flow murmur
•
Widely split S2
•
Split S2
•
Increased P2
•
Normal P2
•
rsR’ in V1
•
May have rsR’ in V1
•
Right Axis deviation
•
Normal Axis deviation
•
Right Arial Enlargement
•
Normal P waves
CLASSIC ASD ECG
ASD CLOSURE
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MITRAL VALVE PROLAPSE
• Mid-systolic click at LLSB, maximal in upright
position
• + late systolic regurgitant murmur at apex
• Look for associated skeletal abnormalities
• slender stature, scoliosis, pectus excavatum
• Marfan syndrome
MITRAL VALVE PROLAPSE
• Diagnosis often over-called
• Prognosis generally excellent
• Potential complications:
• Mitral valve regurgitation
• SBE
• Arrhythmia
• Central neurologic ischemic events
• High risk subset of patients:
• Males, age > 45
• Presence of MR & leaflet thickening
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HYPERTROPHIC CARDIOMYOPATHY
• Most common cause of sudden death in US (35%)
• Sudden death usually occurs in teens and young adults
< 35 years of age
• Occurs in about
2% (1:500) of general population
• Autosomal Dominant with > 400 mutations on 12 genes
• Variable expression and clinic course
• Competitive golf is permitted under guidelines
HYPERTROPHIC
CARDIOMYOPATHY
• Hyperdynamic precordium
• Murmur varies with maneuvers
• SEM at the LSB
• Softer with Hand-grip/ Louder with release
• Standing increases murmur /Squatting
decreases murmur
• History of SOB or chest pain WITH exertion
• Family history of sudden death in a young
relative
HYPERTROPHIC CARDIOMYOPATHY
• Often don’t develop hypertrophy until 14-17
years old
• Absence of hypertrophy does NOT rule
out HCM
• 90% have ECG changes which often
precede echo findings
• Commercially available Genetic testing
(50-60% yield)
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Histopathology of
heart sections
showing
significant
myofibre disarray
and interstitial
fibrosis in HCM
Cell Research (2003) 13, 9–
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HYPERTROPHIC CARDIOMYOPATHY
ACUTE RHEUMATIC FEVER
• New murmur or new onset of heart failure
(tachypnea, S3 gallop, pulmonary edema)
• Murmur of mitral regurgitation at apeX
• Diastolic decrescendo murmur of aortic regurgitation
• Pancarditis- can involve pericardium, myocardium
and/or valves
ACUTE RHEUMATIC
FEVER
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JONES CRITERIA
•
Evidence of recent Group A hemolytic Strep infection
• Plus 2 major or one minor criteria
MAJOR
MINOR
Carditis
Athralgia
Polyarthritis
Syndenham’s chorea
Fever
Erythema marginatum
Prolonged PR interval
Elevated acute phase reactants
Subcutaneous nodules
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13 YEAR OLD WITH SEVERE
MITRAL REGURGITATION
NEW ENDOCARDITIS
RECOMMENDATIONS
•
•
•
•
•
•
Prosthetic material used for cardiac valve repair
Previous endocarditis
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material
or device(surgical or catheter intervention ) for the first 6 months after
the procedure
Repaired CHD with residual defects at the site or adjacent to the site
of a prosthetic patch or prosthetic device
Cardiac transplantation recipients who develop cardiac valvulopathy
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SUMMARY
• Most murmurs in childhood are innocent
• In sick patients – the ECG and CXR will
help differentiate a flow murmur due to
fever versus a pathologic murmur
• When in doubt…. Feel free to call for help
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