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’.