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Transcript
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’.