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Innocent Heart Murmurs
Mansour Al-Mutairi MD
Consultant Pediatric cardiologist
King Abdulaziz Cardiac Center
Assistant Professor, Cardiac Sciences
KSAU-HS, NGHA
Riyadh , Saudi Arabia
Misconceptions
Innocent Heart Murmurs
Patient with Heart
Murmur
Innocent Heart Murmur
Innocent Heart Murmurs
Innocent Heart Murmurs
Characteristic’s of Innocent Murmur:
Innocent Heart Murmurs
Characteristic’s of Pathological Murmur:
Innocent Heart Murmurs
Classification of innocent murmur:
• Four systolic innocent murmurs:
o Still’s murmur or vibratory systolic murmur
o Physiological or functional pulmonary flow murmur.
o Peripheral Pulmonary arterial stenosis murmur of
the newborn.
o Aortic systolic murmur.
• One continuous innocent murmurs:
o Venous hum.
Innocent Heart Murmurs
Still’s Vibratory Systolic Murmur:
• Most common , described by George F. Stills in 1909 as
“A twanging sound”
• Peak incidence in children 3 to 7 years, disappears at
puberty
• Musical, vibratory, low to medium in pitch, early
systolic ejection murmur.
• Maximum at LLSB and extending to apex, loudest in
supine position and change in character with upright
position but seldom disappear.
• Turbulence produced by the physiological narrowing of
the LV outflow tract.
• Highly associated with false tendons (16.8%).
Innocent Heart Murmurs
Physiological or functional pulmonary flow
Murmur:
• Early systolic, crescendo-decrescendo, grade II-III
at LUSB.
• Best heard in supine position (↑ by pectus
excavatum).
• Decreases during upright position and held
inspiration.
• Turbulent flow at the origin of the RT & LT
pulmonary arteries
• DDx the murmur of ASD-II.
Innocent Heart Murmurs
Peripheral Pulmonary Stenosis of the
Newborn:
• Short early to mid-systolic ejection murmur of medium
pitch & intensity at the axillae and back.
• Heard in newborns and infants less than 1 year.
• Result from the turbulence in the PA’s.
• It increase with ↓ heart rate.
• DDx is PPS, ASD-II.
Innocent Heart Murmurs
Aortic Systolic Murmur:
• Short, low to medium pitch.
• Arise from the outflow tract in older children and
adults.
• Audible maximally in the aortic area.
• DDx from the systolic murmur of the HCM
especially with history of sudden death or +ve FH
or if increase with Valsalva maneuver.
Innocent Heart Murmurs
Venous Hum:
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The most common type of continuous innocent murmurs.
The diastolic component is louder.
Whining, intensity varies.
Increased when child sitting / standing ,neck extended and
looking away from the examiner.
Disappear with lying down and occluding neck veins with
fingers.
Louder at high right sternal border and infraclavicular area
however sometimes maximum on the left or equal in intensity
bilaterally.
Result form turbulent blood flow at the junction between JV
and the SVC.
DDx PDA.
Innocent Heart Murmurs
Innocent Heart Murmurs
Neonatal screening exam:
Innocent Heart Murmurs
Neonate and young infant
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Older child
Innocent Heart Murmurs
Variable murmur ( Yes & no !)
Innocent Heart Murmurs
FH:
Hereditary disease, CHD, RF, sudden death.
Pregnancy :
Infections, medications, smoking or alcohol intake.
Postnatal:
Birth weight, weight gain, feeding pattern, cyanosis, squatting,
S.O.B, tachypnea, chest infections, exercise intolerance, chest
pain, joint pain and neurologic symptoms.
Innocent Heart Murmurs
Clinical examination:
Inspection:
General appearance, nutritional status, dysmorphism, syndromes,
clubbing and signs of RD.
Palpation:
(rate, regularity, volume, delay),
(proper cuff), apical
impulse and PMI , hyperactive precordium and thrills.
Auscultation:
Heart sound and
Others:
Abdominal examination.
.
Innocent Heart Murmurs
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Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
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Innocent Heart Murmurs
Complete heart block
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
Innocent Heart Murmurs
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Innocent Heart Murmurs
Innocent Heart Murmurs