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Diagnosis and Management of Heart Murmurs in Children

Jerome Liebman
Pediatrics in Review 1982;3;321
DOI: 10.1542/pir.3-10-321

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2. it is easy to explain why these normal murmurs are often so well heard on the surface of the child’s chest (Fig 3). As all nondiseased people have a murmur in the root of the aorta and pulmonary artery. making the palpation the chest casual may heart appear and making roentgenogram the large image large to on to observation. with experience. many physicians have come to believe that cardiology is a ‘black box’ field. The liver need not be palpated in the standard textbook way. (The term “functional murmur” is not used by this author. that murmur will become louder. is very close to the chest wall.aappublications. of Heart of Pediatric and Children Cardiology. and with the ability to make appropriate referrals for further evaluation and to counsel the child and family appropriately (Topics 81/82). An * Department bow Babies land. then only a right arm blood pressure is necessary. and listen with ears close to the pipe. Echocardiography provides such remarkable tools for the cardiologists and has had such publicity. find a water pipe. the heart of the child. the redness is usually an associated congenital anomaly due to congenitally large capillaries. a heart murmur will be documented (Figs 1 and 2). causing abnormal murmurs which are a function of this increased flow. MD* The physician taking care of children must meet the problem of an easily audible heart murmur almost every day. If the femoral pulses (felt simultaneously with the right as well as left brachiai) are well felt. Although this may indicate mild cyanosis. As the water goes through the pipe it can easily be heard. ‘ EDUCATIONAL 22. the murmur is again recognized to be louder. entirely dependent upon sophisticated equipment and methodology. Most people find that the fingernails are an excellent place for observation. I have found that palpating from below upward frequently causes guarding #{149} vol. both noninvasive and invasive. as indicated. the fingers will sometimes be red and shiny in many congenital cardiac lesions. This is four times the normal flow through normal pulmonary and tricuspid valves. Mild cyanosis may be difficult to recognize. One should also estimate the pulse pressure. and as the heart of the child is close to the chest.Diagnosis Murmurs Jerome and Management in Children Liebman. Rales in a child are more likely to indicate pneumonia than pulmonary edema. by the electrocardiogram89 and the chest roentgenogram. the examiner will be able to be more accurate in ‘ CARDIOVASCULAR EXAMINATION determining a narrow. If one places an intracardiac phonocatheter at the root (origin) of the pulmonary artery or root of the aorta in all nondiseased people. then two upper extremities and one leg pressure should be measured. anterior-posterior In Fig 4 is shown the form used for the physical exmination of a patient being evaluated at the congenital heart ambulatory unit at Rainbow Babies and Childrens Hospital. cause the heart to assume a position that is more toward the right anterior oblique. A useful analogue to explain the normal murmur to families is to suggest that they go to the basement of their home. 5. of course. that is a murmur. s Hospital.8/i 00 (although it may approach 1 / 100). OBJECTIVE Appropriate recognition of the common functional heart murmurs. Therefore. If there is a decrease in pediatrics in review average. with ability to differentiate them from organic murmurs.’4’ abetted. and if then one finds an angle in the pipe where turbulence is likely.org/ at Pakistan:AAP Sponsored on November 20. 3. for functional murmurs are not normal. femoral pulses ora decrease in one of the brachial pulses.) The incidence of congenital heart disease is approximately . In addition. but it is far from true in the majority of situations. If one finds the input to that water pipe and turns the spigot such that the space for the entering stream is narrowed. the physician must be able to perform an excellent cardiovascular examination. should have an approach to making the differential between abnormal and normal murmurs. with knowledge of clinical features of common cardiac defects. The matrix of the evaluation is the physical examination. A left chest prominence may indicate a large heart-but make note of a pectus as well as a narrow Both chest of these diameter. for. As medical knowledge has expanded. it is usually not necessary. As pediatric radiologists are constantly reminding us. the pediatrician ‘s differential diagnosis when he or she hears a murmur in an asymptomatic child starts with the likelihood that the murmur is normal. In order to do so. particularly the preschool-aged child. Some of the items in Fig 4 deserve comment: 1. RainCleve- example is provided by the hemodynamics in atrial septal defect with a 4:1 pulmonary to systemic flow ratio. 3 no. 4. 10 april Downloaded from http://pedsinreview. or wide pulse pressure than will an ausculted pressure in a baby or a not very cooperative preschool-aged child. and. and (2) because each great artery arises from the ventricle at an angle. This form helps in maintaining the discipline required for an appropriate cardiac examination. but that number is small by comparison with the numbers of children with normal murmurs. The latter is certainly the case for complex disease. that it is often utilized unnecessarily. proximal to the nails.13 This murmur is present for two reasons: (1 ) because the origin of each great artery is narrower than the ventricle which ejects the blood into it. In the evaluation of most children (after infancy) with heart murmurs. 2013 1982 PIR 321 . and should be able to figure out what the common cardiac lesions sound like.

This is a typical normal aortic ejection murmur which was audible on surface of chest at fourth left interspace at left sternal edge.Heart Murmurs Fig 1 . A liver that is 5 cm down from the rib margin at the nipple line.org/ at Pakistan:AAP Sponsored on November 20. period followed second sound on surface of chest. Fig 2. has been recorded. moderately enlarged. The liver’s left lobe appears to be preferentially enlarged in congestive heart failure. Intracavitary phonocardiogram in root of aorta of normal 7-year-old child. it is better to feel lightly from above downward. especially to the left of the midline. for exampie. 5. Another type of hyperdynamic impulse is recognized by putting the outstretched hand vertically up the left sternal border. etc. For me. or greatly enlarged to the anterior axillary line. lntracavitary phonocardiogram in root of pulmonary artery of normal First sound (Si) is shortly after electrocardiogram (ECG). PIR 322 pediatrics in review #{149} vol. inside the nipple line. The edge is then easy to delineate. as in significant mitral valve regurgitation. The normal left ventricular impulse rocks the hand toward the sternum from the apex. 7. A thrill in the chest indicates only that there is a grade IV or louder 1982 Downloaded from http://pedsinreview. and does not extend to the left may be normal. The right hand is then extended outstretched from the sternum toward the apex. that hand is also attempting to determine whether the heart is of normal size. that is not tender. 2013 . after which the standard measurement below the right costal margin is made at the nipple line. but usually satisfactory in prepuberty) that impulse represents the activity of the right ventricular outflow tract and pulmonary artery. The normal cardiac impulse after infancy is a left ventricular impulse. This is typical normal pulmonary ejection murmur which was not audible 9-year-old child. 6. S is shortly after ECG. The physician should stand with the child’s head to his left. 10 april and loss of the edge. There is a sound-free by diamond-shaped high frequency murmur which ends well before pulmonary (52).aappublications. One should also try to specifically outline the liver-frequently making a drawing including the liver’s extent to the left. There is a sound-free period followed by diamond-shaped high frequency murmur which ends just before aortic second sound. At the same time. The right ventricular impulse (always abnormal after early infancy) rocks the hand toward the apex from the sternum. The hyperdynamic upper left sternal edge gives an excellent clue to significant left-to-right shunts. The abnormal left ventricular impulse is an accentuation of the normal and often causes retraction of the skin in systole. 3 no. gradually extending the hand lower and lower. In children (better in skinny infants than chubby teenagers. whereas a 3-cm liver with a large left lobe extending well to the left of the midline may be quite abnormal. It is also determining whether the apex is hyperdynamic. There will frequently be systolic retraction of the skin outside the apex.

Murmur starts after 5.org/ at Pakistan:AAP Sponsored on November 20. the second sound (52) everywhere. This type of auscultation is called ‘dissection. One listens to everything first in order to evaluate the timing of systole and diastole. the normal split of S2 on inspiration is wide. any variance from the above is a likely concern. S is. because the pulmonary closure is not being heard at all and a loud aontic closure is being transmitted down the descending aorta. is a normal tncuspid closure sound following the mitral. is chanactenistic of tetnalogy of Fallot. One must be quite compulsive in listening to the heart sounds to train oneself to listen to one sound at a time everywhere. associated with the hemodynamics that causes a large puImonary artery. unless right ventricular pressure is high. particularly the former. However. A ‘thin’ second component heard after the apical component at the lower left sternal border. External phonocarcitogram of normal at left sternal edge. Such sounds as fourth sounds (54) and opening snaps are so rarely heard in children that the pediatrician would be better off concentrating on the others. best heard at the apex. whereas on expiration. This murmur on chest is a normal murmur aortic ejection murmur. 10 april Downloaded from http://pedsinreview. The pulmonary ejection click is better heard on expination than inspiration (on only heard on expiration). the pediatrician should listen to systole alone. Right ventricular systole is. there is no chance! S1 is made up mainly of mitral and tricuspid valve dosures. 3 no. is approximately two-thirds systolic. even in the absence of heart murmur. 2013 1982 PIR 323 . Although there is variation of the normal. the third sound (Se) everywhere. averaging 40 to 50 msec. Large left-to-right shunts may cause faint thrills at that point. 5-year-old child recorded at fourth left interspace and stops well before 52. important examples are: (a) the more severe the pulmonic stenosis. particularly in inspiration. It is associated with rapid filling of the left ventricle. therefore. (d) a narrow split on no split may also be present because of pulmonary anteny hypertension (for the high diastolic pressure closes the pulmonic valve early. the more delayed (and soften) is pulmonary closure. Without going through all the possible abnormali‘ ‘ ‘ ‘ ‘ Fig 3. Aortic ejection clicks are less sharp and more clearly separated from S1 than are pulmonary ejection clicks. prolonged with a delayed pulmonary closure on inspiration. With inspiration. 8. the split is widen than normal and is approximately the same on inspiration and expiration (‘ ‘fixed’ wide split). lightly applied to the chest. a thrill in systole at the suprasternal notch is virtually diagnostic of either pulmonic stenosis or aortic stenosis. but not usually a thrill. It should be clean in evaluating children with heart murmurs that there is nothing more important than analysis of the ‘ pediatrics in review second sound. of increased intensity and loudest at the lower left sternal bonder. Ejection clicks are either pulmonic or aontic. and then the various clicks everywhere. (e) a single 52. The pulmonary ejection click.sten to the first sound (Si) everywhere. A systolic thrill over the carotids is diagnostic of aortic stenosis. Clicks are extremely important. so that length of murmur is a medium frequency murmur. and then diastole alone. There was no transmission to itary phonocardiogram at root of aorta was 2). which sounded back and excellent transmission to neck. This vibratory. Finally. and coarctation of the aorta may cause a very active systolic impulse at the suprasternal notch. They are best heard vol. there may be no split or a narrower split. therefore. If the physician tries to evaluate by listening to everything at once. as is an abnormally loud apical S. usually maximal at the apex. (c) a narrow split on no split may be present in significant aontic stenosis because pnolongation of left ventricular systole causes delayed aortic closure. is a sharp sound heard close to (on almost on top of) the first sound.aappublications. lntracavin all normal children studied (similar to that of Fig and is believed most likely to represent a normal ties of 52.CARDIOLOGY murmur at that point. A normal 53 is soft. best heard at the upper left sternal bonder. there is an increase in negative intrathonacic pressure so that more blood enters the right side of the heart. and not easy for most people to hear. Then one should l. A night ventricular S (best heard at the lowen left sternal borden) is always abnormal after early infancy. (Aortic closure is slightly early. (b) in atnial septal defect. S is a low frequency sound which is heard best with the bell. 52 is made up mainly of aontic and pulmonic valve closures and is normally best heard at the upper left sternal bonder.) Therefore.

nall LV eormal) LV (aboor.Murmurs Heart unl(. usually one-third to one-half way into systole. Murmurs.. is rarely recognized. In nondiseased hearts in the preschool-aged child. The readily recognized normal murmurs in children after infancy are: 1.oo seen at the lower left sternal edge and/or the apex-or even as far lateral as the anterior axillany line. needing not only concentration but lots of practice.e’cse Dypoea Tests Ordered (II’S X. Attempts should be made not only to grade them in the standard way for intensity (I to VI for systolic murmurs. There is no variation with respiration. but. heard with the child lying down only (Fig 6).nn.ps Rales L’oet Spleen Fe. the murmur obscures the first sound.org/ at Pakistan:AAP Sponsored on November 20.al - _________ Exasiner Staff Phosiciso.ic Apex J Hypsrdyxasic Upp.aappublications.’ dg’tahs Dosage Sympto’lts ot one’ DATE OF EXAR1NATION: P. Nesatclogy: Second Focrth Chck Ejection: Mon-ejection: Grade MUrmUrs Fig 4. also at the lower left sternal border. A systolic ejection murmur at the lower left sternal border may be 1982 Downloaded from http://pedsinreview. They are associated with the hemodynamics that cause a lange ascending aorta. 10 april Heart Ambulatory Unit. Such a statement as. DATE: detotet’ty Th. It is easy to hear-with concentration.obleos Signed: Esambiaftoe Physical _________ ___________ neai Wt % BlOOd p’esscte a. I to IV for diastolic murmurs) but also to describe the length and the pitch and to try to delineate the relationship of the murmurs to each sound. The most important differentiating point is that in ventricular septal defect. Diastolic murmurs may be both high and low fnequency. medium to high frequency diastolic murmur at the lower left sternal bonder. This murmur. the physician must now say “I am now going to listen for a high frequency diastolic decres- vol.it SHEET Today’s ECG DIAGNOSIS teteresi History E. For example. the most common abnormal munmur is that of a small ventricular septal defect. Low fnequency diastolic murmurs are more difficult to hear.ms legs Ht_ ott Signed: (esp. Nonejection clicks are midsystolic.npolse N V normal) Dasc”plOn of cardtac OnpUlSe N V aboor. even if it is only grade I. should be compulsively described the way the physician hears them. systolic and diastolic.Ray Naoe Deoelopo’e”t Echo Echo Tole. the munmun may be quite diamond-shaped. if it is missed it does not matter. is abnonmal.lI Rettact’oos Toes let ‘ate Edettta Chest Fatgets Cyanosts Clubb’ng Fleonsss Resptato’y TREATMENT __% got ‘ale (‘Ste’Costal) (daphtag’ttat’c RETURN EVALUATION pIses OF TODAY’S DATE TESTS: Tests ccc: Ordered on Motors: Eci VCG: vci Heest X-Ray: Cardac .. the most common nonmal murmur heard in the chest is a diamondshaped ejection systolic murmur.r Left Soc Sternal Edge tJ Echo Echo SouOdsot Mac M SpitIng Respjratory ID) (11) Echo (20) ller:ato logy (21): change MET. “there is a systolic murmur at the apex” may be useless. PIR 324 The murmur pediatrics usually in review ob#{149} in Rainbow Resp Change Babies SOlItARY and Children AiS s Hospital PLAN: Congenital scunes the first sound and is at the lower left sternal edge. of course. indicative of a prolapsed mitral valve (Fig 5). although the normal ejection systolic murmur at the lower left sternal bonder is often vibratory (Fig 3) and the vibnating nature is usually best appreciated with the bell. although not rare. as well as no evidence for specific cardiac abnormality. A high frequency diastolic decrescendo murmur at the second through fifth interspace at the left sternal edge.. The direction often given to students is to ‘tune yourself low. If the defect is small. Nonejection clicks may be multiple. cendo murmur. The standard teaching is that diastolic murmurs are always abnormal. ‘ ‘ ‘ ‘ ‘ Diagnosis of Normal Murmur The diagnosis of a nonmal murmur is based on certain positive descriptions of normal murmurs.drcgs) RETURN L. 2013 . Most systolic murmurs ane best heard with the diaphragm.Ity Hospitals Congenital of Cleoeland Heart EXAM Asboistory J. 3 no.nal) D’ftose-Sep NV * L Echo Morsel leart ( Apex Hyperdyna.aoce - ii 20 Hatoiogy Ciasos’s q-tll”g The’apy010. They may or may not initiate a late systolic murmur and are always abnormal. In order to hear it. but one type of diastolic murmur can be normal-a short (up to grade II). Examination Phase sheet Ocaltyard Length for a child Macma: Locate” being Ttansm:ss..

could not be pant of this review. is usually not heard in the back. With increasing age and size. Three times normal flow traverses the mitral and aortic valves. Aortic ejection clicks also do not vary with respiration.46 the cardiac longstanding outputs nature Patent may extra in the cause outflow greater. but can be recognized at any age. The left atrium and left ventricle contain three times the non- mal volume. This murmur is particularly common in adolescents. which does not vary with respiration. This sharp sound (C) is a nonejection click. namely. diamondshaped early diastolic murmur heard at the lower left sternal edge.org/ at Pakistan:AAP Sponsored on November 20. axilla which transmit and back. The findings. #{149} vol. 3 no. External phonocardiogram of 6-year-old girl with mitral valve prolapse and trivial mitral regurgitation. A normal diastolic murmur may be a grade I or II short. Newborns do not commonly have normal murmurs except for the ‘functional’ peripheral pulmonic stenosis. 2013 1982 PIR 325 . but are very close to first sound. although rarely it may just be softer. Intracavitary recording had also been made in left atrium where it was almost identical with that seen at apex. causing ‘functional’ murmurs. We believe (but do not have absolute evidence) that this is the normal aortic ejection murmur. The but the disease to develop functional nature of the murmurs has the same explanation as in the various left to night shunts. 2. up to grade Ill in intensity. of the muscle tracts. 4. Abnormal left ventricular impulse with candiomegaly. but readers are urged to study those representing common acyanotic lesions in the literature. The diagnosis is easily made. The murmur is apparently due to the sharp angle made by the subclavian vein as it enters the superior vena cava.aappublications. but is frequently very well transmitted to the neck. There are simultaneous phonocardiographic registrations at left upper sternal border (LUSB) and apex. are likely to cause even louder murmurs than iron deficiency because not only are sions and to determine what is happening. at the third or fourth intercostal space. the murmur usually disappears. 5. Frequently. is particularly common in the preschool-aged child. PHYSICAL EXAMINATION OF COMMON CARDIAC LESIONS WITH NONINVASIVE FINDINGS output In order to understand these le- states may cause heart murmurs in patients with nondiseased hearts. is usually not transmitted to the back. such as that associated with sickle cell disease. 3. 10 april Downloaded from http://pedsinreview. are: 1 Increased pulse pressure. Following the click is a late systolic murmur which ends at 52. A venous hum at the upper right chest may be heard while sitting up but rarely when lying down.CARDIOLOGY Fig 5. Note that there is a sound-free space slightly more than halfway into systole. the angle becomes less and the mur- pediatrics in review A 3:1 S) flow Ductus Arteriosus pulmonary ratio (PDA) to systemic in PDA will (P/ be associ- ated with three times normal pulmonary artery and pulmonary venous blood flow. by ejection murmurs at the upper left and upper right sternal to each borders. but is frequently very well transmitted to the neck. We believe (but do not have absolute evidence) that this is the normal pulmonary ejection murmur. because of space limitations. an understanding of the box diagram of the heart is remarkably useful. present because the angulation between the main pulmonary artery and each branch may be ‘ ‘ sharp. Thynotoxicosis and iron deficiency are excellent examples. Various high cardiac muns disappear. therefore. where there is a sharp sound. A systolic ejection murmur at the upper left sternal border may be up to grade III in intensity. When the patient sits up. 6. this murmur is very vibratory in nature. while lying down. Hemolytic anemias. 2. Such diagrams. ‘ ‘ . The murmur is of medium-high frequency and changes intensity as the neck is moved right and left. This angle is much greaten when sitting up than when lying down. but can be recognized at any age. Pulmonary ejection clicks are louder on expiration and are usually closer to S. as well as respiration marker (inspiration is higher on trace) and lead 2 electrocardiogram.

night ventnicular hypentrophy (RVH) is additionally present. (Because the atrial defect is likely to be nonrestrictive and because flow through the ASD is in systole and diastole. 6. Small defects are often associated with soft murmurs because the very restrictive defect does not allow much flow. low frequency rumbling murmur owing to increased flow traversing a normal mitral valve. ECG-RVH. The intensity of the murmur also varies. Systolic murmur maximal at the third. Ejection murmur is much decreased in intensity from that in root ofaorta and is believed to be transmitted. The findings. 5. Split Fig 6. the wider the split. pulse 2. Chest roentgenognam-cardiomegaly. 7. 3. to small pulmonary ascending aorta arterial vascular- ity. 8. pulmonary artery vasculanity (endon third Atrial vessels well seen of the lung field). Echocandiogram demonstrates and abnormal (very useful) night volume overload septal motion. I pulmonary artery size. the the left rises just pressure murmur of the ventnic- before curve. 5. 4. mainly because the high diastolic pressure is associated with earlier closure of the pulmonic valve. 3. even with the patient sifting up. and very lange defects can be associated with soft murmurs because a high pulmonary vascular resistance has developed and does not allow much flow. Hypendynamic nal border.Heart Murmurs normal size. with terminal conduction delay (Fig 7). and night atrium and right PIR ventricle contain three times the nonmal volume. Soft systolic ejection murmur (grade III on less) at the upper left sternal bonder owing to increased flow traversing a normal pulmonary valve. upper especially of the varies with but whose (night left sten- high. therefore. depending upon how much flow is going across the defect. If the flow is little. like water going down the Colorado River rap‘ ‘ ‘ ids. flow (ASD) in review s which mally. often being only two-thirds to three-fourths length. 7. the higher the pulmonary vascular ne- sistance. 6. Ventricular Septal Defect (VSD) The same thought process as for the other two left-to-night shunt lesions gives us the following for a 3:1 P/S flow ratio: Diffuse and left) with 1 2. Intracavitary phonocardiogram from body of left ventricle of 7-year-old child (same child as Fig 2). this murmur peaks in late systole and the systolic portion is often uneven’ in character. usually maximal at the upper left sternal bonden. Continuous murmur. with respira- tions.) Three times normal flow traverses the tricuspid and pulmonic valves so that there are ‘functional” murmurs through the valves. Short grade II diastolic medium-tohigh frequency murmur was heard at the fourth left interspace. If the 1982 Downloaded from http://pedsinreview. Chest roentgenogram-cardiomegaly. There is no murmur of blood traversing the atrial opening. fourth. . left to right shunt across the ventricular septum may begin before the rising left ventricular pressure exceeds left atnial pressure to cause mitral valve closure. An increased intensity pulmonary dosure sound is most useful if there is an associated tamboun. Septal Defect in the outer 326 pediatrics 1 . Note that there is a diamond-shaped medium to high frequency murmur in first part of diastole. Mid-diastolic. 10 april right size. are: cardiac impulse cardiomegaly. This is a typical normal diastolic murmur. while lying down only. ECG-left ventricular hypertrophy (LVH) usually. 4. Mid-diastolic frequency murmur at the lower left sternal bonder owing to increased A 3:1 P/S flow ratio in ASD will be associated with three times normal pulmonary artery and pulmonary yenous flow.org/ at Pakistan:AAP Sponsored on November 20. if there is pulmonany hypertension. pulmonary artery ‘ vol. Hyperdynamic upper left sternal bonder. Widely upper split does not left ster- second vary sound. ? increased ascending aontic size. Hyperdynamic nal bonder. which obscures or partially obscures the first sound. the narrower the split. 4. 8. Soft systolic ejection ‘ murmur (grade Ill on less) at the upper right sternal borden owing to increased flow across a normal aontic valve. or fifth left interspace. Gain has not been changed. Abnormal with right which ventricular im- cardiomegaly.aappublications. 2013 . 3 no. The reason for the latter is that ulan pressure curve the right ventricular therefore. 3. the left atnial flow does not stop there-causing no enlargement. medium-to-low traversing a normal tricuspid valve. second sound respirations analysis is nonex- tremely important: the lower the pulmonary vascular resistance. mainly because pulmonany closure is delayed. The murmur of ventricular septal defect does not have to be full length (holosystolic). the murmur is soft regardless of the size of the defect.

6. Consequently. larger the the more opening. the defect. Some of the VSD flow presumably goes right through into the pulmonary artery. Abnormal right ventricular impulse with no or little cardiomegaly. not vary- respirations. Roughly. Pulmonic ejection expiration versing at the (as better blood is tra- in expiration). normal ascending aorta. best heard at the lower left sternal border. including increased left atnial size. 7. Valvular Pulmonic Stenosis (PS) Valvular pulmonic stenosis is almost invariably valvular as infundibulan pulmonic stenosis is almost always associated with a VSD. the the restrictive fect. narrowing the split and even becoming inseparable from pulmonic do- sure (no split). the ECG is normal. 5. I pulmonary arterial vasculanity. with no on little 2. Suprasternal thrill plus a carotid 3. In addition. regardless of the defect. Coarctation the right ventricular pressure is expected to be significantly less than systemic level. the left ventricle contributes more than However. well sep- the first sound. 5. but cleanly stops before a audible aortic closure arated ing border. Ejection systolic murmur usually at the upper night sternal border associated with a systolic thrill if the murmur is loud (grade IV). but later in childhood. 5. In more severe stenosis. (ST and T abnormality indicates potentially grave Severity. even sometimes being over the sternum or the upper left sternal border. Intensity of aortic closure is normal no matter what the severity (although it can actually even be somewhat increased). 6. the left ventricle must propel the blood through the VSD. 1. the imal at the more plateau-shaped murmur This click the de- first sound the having upper will be. roentgenogram will not show arteries. The proximal branches may also be large. 8. the will ECG show RVH. In general. LVH with larger flow and frequently additional RVH. less the valve left pulse suprasten- max- sternal be night on top of the so that it is recognized a loud ‘first left sternal border ‘ ‘ by at the (not likely) that is louder on expiration than inspiration. and/or left axilla. within the context of the high on flow. soft. the more diamond-shaped murmur will be. Roentgenogram-normal Aortic size end-on arterial Stenosis Valvar stenosis is the most mon form of aortic stenosis. 1. aithough the night ventricle must do some extra volume work as well. Aortic ejection from with candiomegaly. 2.org/ at Pakistan:AAP Sponsored on November 20. im- In review of Aorta pulses Diminished in relation or absent fernoral to the right brachial #{149} vol.) In mild cases. Soft systolic ejection murmur (grade Ill on less) at the upper left sternal bonder owing to increased flow traversing the normal pulmonic valve. ECG-normal in small defects. but the outer third of the chest maximal murmur in that area usually indicates one of the types of subvalvar aortic stenosis. higher and does the the the right more the larger right ventricle.aappublications.) For the stenosis to be significant. As severity increases. 6. in congestive of the size and if the patient is not heart failure. With increasing severity and prolongation of left ventricular systole. 8. apex. the mun- 3. (Occasionally. the split of the second sound widens and the intensity of pulmonary closure dimin- ishes. pulmonary artery size. systolic thrill. Systolic mur will be at least grade IV. If the pulmonary blood flow is large. then the left yentnicular volume is also large. This murmur may be difficult to recognize murmur across because the of flow going the ventricular transmit so widely louder left to night septum may as to obscure it. extends and past aortic ventricular pressure if the murmur closure. but occasionally hyperdynamic high up. the night is likely to be suprasystemic. Split of the second sound is slightly wide with mild stenosis. sound. the right ventricular pressure is likely to be in the neighborhood of systemic pressure. The the longer the more the the later the peak.) 7. associated with a normal (to increased intensity) pulmonary closure sound. Mid-diastolic low frequency rumbling murmur at the apex owing to increased flow traversing a normal mitral valve. If the second sound is normally split. Roentgenogram-normal size or minimal cardiomegaly with a prominent ascending aorta.CARDIOLOGY flow is great. there is so much prolongation of aortic closure that aortic closure occurs after pulmonary closure. so that pulmonary vascularity is normal. 7. The apparent loud first sound is actually a pulmonary ejection click. left closure and the being too distorted pulmonary to snap Ejection murmur at the sternal bonder (associated a systolic grade thrill if the murmur is short severe the cleanly and stenosis. ECG-RVH. but the vectorcardiognam will usually be abnormal. 4. Chest noentgenognam-cardiomegaly. 2013 1982 PIR 327 . Normally active left sternal border. the decreased intensity second sound is due to the murmur obscuring the aortic valve closed. ECG-LVH. (Valvar aortic stenosis can be maximal at the lower left sternal border in infancy. On rare occasions. 10 aprIl Downloaded from http://pedsinreview. and a split on expiration (paradoxical split). The location of the maximal intensity of the murmur can vary greatly. the ventricular pressure. aortic closure becomes closer to pulmonic closure. a on minimal cardiomegaly with a prominent pulmonary artery. 1. 3 no. an occasional right descending aorta. upper may click. murmur and if the murmur upper with murmur IV). in terms of volume work. the murmur must be nearly full length. Abnormal left ventricular pediatrics com- Coarctation of the aorta is almost always in descending arch near ongin of left subclavian and ligamenturn arteriosus. 4. The result is a single second sound on inspiration. the stenosis is mild. If the stenosis is loud- is mild. severe aortic stenosis is associated with a normal standard ECG. notch systolic click. thrill nal notch. when the murmur extends to aortic closure. even if the child is asymptomatic.

More some- very loud. exsecond sound (Fig 5). Valve Prolapse3 1 Questionably abnormal left ventricular impulse. the recognition that the split is narrow with increased intensity pulmonary on left axilla. a ‘functional’ flow through valve results. The murmur is characteristically de- scnibed as holosystolic (throughout systole) but this is not necessarily a good term. Hyperdynamic apical impulse varying with severity as described above. so that RVH remains long after birth. Systolic murmur can be as soft as grade I or as loud as grade IV. . 10 aprIl 1982 Downloaded from http://pedsinreview. the murmur while lying may down be late systolic and holosystolic when up. as part of the evaluation. so that poststenotic make a ‘3’ ‘ the pne- dilation ‘ sign. like as within be soft classic the murmur tiated sitting pafre- regungiharsh on virtually thing is is late systolic. 1 Abnormal left ventricular impulse with little on no to great candiomegaly depending upon the severity of the lesion. Sometimes clicks are multiple and the times they are to miss. then there must be a large forward flow (no diastole) across the valve. II. sitting 4. back. 2013 . The murmur should be prominent in late systole and may even peak at that time presumably because function. an indentation may be recognized in the descending aorta closure is a potentially grave prognostic sign. However. 6. nary but increased this venous Mitral in increase severe is pulmo- in origin. to halfway into systole. Active pulse. 8. 5. late systole is more important. ECG-LVH (normal. for the murmur usually does not obscure the first sound. Roentgenognam-varying diomegaly depending if mild). miwhen Occa- the murmur may even be lying down. atrium is lange. Consequently. Roentgenogram-nonmal size or minimal cardiomegaly. tient. on Ill while sitting up. If the first sound is very soft. Increased intensity of aortic closure. May mal (and abnormal a few later). The click’s intensity is not different lying down or sitting up. the murmur just 2. the and as well It may quency. anywhere edge. 3 no. 8. but it is often diminished (for reasons not always clear). and be grade I. 4. In infants. Although the murmur can be maximally heard anteriorly. 4. ECG-LVH (although the younger the child. Murmur of the coarctation is variable. obscuring of that sound by the murmur may be difficult to distinguish. of papillary muscle dys- 6. diastolic and ‘ murmur of increased the nonstenotic mitral This murmur is middoes not go into late ‘ diastole (as would mitral stenosis). Prominent abnormally be norminutes ante- nor and mon as sionally. on whooping-on anything else. the left on near the apex with maximal be virtually over sternal absent the loud an- in the left scapula or slightly lower. The ascending aorta is normal unless there PIR 328 pediatrics in review past #{149} the stenotic and plus the notch Mitral arch. 5. sionally. rarely im- supnasternal with a thrill. but it may also be groaning. 2. 7.aappublications. on occasion even diminished to the level of the femonal artery pulse. by the click and louder up than lying down. It may be very soft (grade II) is an additional aontic valve problem. Therefore. Nonejection mid-systolic click at the apex. The character of this tnemely variable from murmur patient tient. Late systolic ning with the tending to the murmur begin- midsystolic click. or it may be that the left subclavian artery is hypoplastic at its origin at the coarctation. Occathe T wave may even be to the right gitation. Occasionally. The important that As the down. coarctation to In fetal life. The left bnachial pulse may be the same as the right. Pulmonary The left vascular- ity may be cases. it should be the night arm.Heart Murmurs artery pulse. lying to recognize position. The latter is believed to be a remnant of previous fetal hemodynamics which occurred when the night ventricle may have been sending blood through the the descending aorta. it can be hypothesized thathypenpIasia of the ventricular muscle may be a response to increased workload as well as hypertrophy. Abnormal left ventricular pulse with no or little cardiomegaly. be expected in 7.org/ at Pakistan:AAP Sponsored on November 20. ECG-vaniable. however. The latter may be caused by the left subclavian artery arising below the coarctation. if only one arm blood pressure is measured along with one leg pressure. RVH is usually present. impossible often. Bicuspid aortic valves are very commonly associated. If the mitral regurgitation is considerable. 3. Regurgitation Mitral regurgitation can be con- genital or due to rheumatic heart disease. No candiomegaly. Normally on even slightly widely split second sound is expected because the left atrium is so compliant that it tends to accept the large volume load without much increase in left atrial and thus pulmonary venous pressure. The timing is one third . Aortic ejection present unless there despite severe notch click is not is associated disease and is rarely more than grade III. Presumably a high pulmonary venous pressure with resulting high pulmonary artery diastolic pressure is the cause. along it may even teriorly. but it may be earlier when the child is sitting murmur is softer while the click in that 3. Unlike ventricular septal defect with left to night shunt. particularly near the spine. they are very soft and easy to miss. the greaten the possibility that RVH may be present). to being very soft if the valve is very distorted. It is ejection in type and starts clearly after the first sound. The frequency is usually high. First sound varies from being loud if the valve is freely mobile. abnormality of the aortic valve. the murmur extends into diastole due to continuous flow through the coarctation (not due to collateral vessels). despite (These trivial mitral regurT and U wave ab- vol. may be easier up. Occasionally. in which early systole is very important in making the diagnosis. On occasion. canupon the amount of regurgitation. absent is exto pa- same high mitral tation. im- 3. superior T waves are comare large U waves. 2.

Borkat G. rSR’ in both right chest leads. the two murmurs associated with atnial septal defect are both functional murmurs. Phila- deiphia. Pediatrics 42:276. crosses line perpendicular slowly inscribed. 1979. pp 294-323 7. They are not normal. If the auscultatony examination is negative. Sood S: Diastolic apparently normal children. Sreenivasan VV. but almost anterior. Perry LW: The Innocent Murmur. is the term functional murmun. Result is 2. 1968 4. but it is not very specific. Rappaport MB. Adams FH.1#{176}Intracardiac phonocardiographic studies have demonstrated that all people have these normal murmurs. In carrying on the analogue of the water pipe in the basement. Boston.U-ST1 _________ *S it Y4R vi V2 Fig 7. but the patient is definitely not normal and many physicians believe that infective endocarditis pnophylaxis should be given Particularly objectionable. pp 18-61 9. the munmun has not disappeared. Liebman J. however. .) 5. Sprague HB. Rudolph AM: Congenital Diseases of the Heart. in Moss AJ. 1977. daceres CA. Williams & Wilkins. Liebman murmurs in Circulation J: Posterior mitral regurgitation in girls possibly due to posterior papillary muscle dysfunction. Nadas AS. Furthermone. EPILOGUE There is moderate Consequently. 10 april Downloaded from http://pedsinreview. For example. The murmur is merely too fan away from the steth- REFERENCES 1.CARDIOLOGY I _S:i. Chicago. parents love the word “normal. 1960 8. Baltimore. nc. Typical standard ECO child with atrial Septa/defeCt. vector shown to be somewhat right ventricular hypertrophy. 38:755.aappublications. the munmur of mild valvan pulmonic stenosis is surely innocent for life expectancy is believed to be normal. Hirschfeld S: The heart. Little. Fyler DC: Pediatric Cardiology. the diagnosis should generally not be made. New York. the auscultor is now at the other end of the basement. vector is slightly abnormally to right. American Heart Association. For example. 2013 1982 PIR 329 . 1967 vol. Physiologic and Murmurs. in Klaus MH. 1973 10. et al: Heart Sounds and Murmurs: A Clinical and Phonocardiographic Study. Paediatrician 2:251. Ongley PA. Fanarotf AA (eds): Care of The High-Risk Neonate. a function of increased flow through normal valves. Liebman J. Plonsey R: Electrocardiography. Children and Adolescents. Year Book Medical Pubushers. however.org/ at Pakistan:AAP Sponsored on November 20. Plonsey R: Basic principles for understanding electrocardiography. Liebman J.” The term innocent murmur is satisfactony. New York. Terminal vector was also normalities have suggested papillary muscle dysfunction as being etiologic in some patients. 46. 1968 3. Emmanovilides Gd (eds): Heart Disease in Infants. Note that the term normal murmur is considered much more suitable than the terms functional murmur and innocent murmur. this echocandiognaphic finding is commonly ovennead so that the diagnosis of prolapsed mitral valve should be made mainly utilizing physical examination. 1 974 6.i4 *0 - II III AVI AVL V4 vs AVF . and when the normal murmur is no longer heard on the chest surface in adolescence and adulthood. Brown and do. ed 2. do. Principles of Heart Sounds American Heart Association Monograph No. WB Saunders do. oscope to be heard. WB Saunders. Liebman J. Echocandiognam-Pnolapse of the posterior mitral valve leaflet posteniorly is characteristic. Grune & Stratton. 3 no. Philadelphia. 1975 pediatrics in review V6 Initial to V4R QRS is normal and terminal and Vi lead axes. 1972 5.

2013 .3.aappublications.aappublications.aappublications.org/site/misc/Permissions.xhtml Downloaded from http://pedsinreview.Diagnosis and Management of Heart Murmurs in Children Jerome Liebman Pediatrics in Review 1982. can be found at: http://pedsinreview.1542/pir.3-10-321 Updated Information & Services including high resolution figures.321 DOI: 10.xhtml Reprints Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/content/3/10/321 Permissions & Licensing Information about reproducing this article in parts (figures. tables) or in its entirety can be found online at: http://pedsinreview.org/site/misc/reprints.org/ at Pakistan:AAP Sponsored on November 20.