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Dr. Victor Grech Cons. Paed. _Cardiol_

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Dr. Victor Grech Cons. Paed. _Cardiol_ Powered By Docstoc
					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   38%
   Atrial septal defect     18%
Pulmonary valve stenosis    13%
Pulmonary artery stenosis   7%
  Aortic valve stenosis     4%
 Patent ductus arteriosus   4%
  Mitral valve prolapse     4%
          Others            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’.

				
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