Cardiovascular

system in
children
 Borders of relative heart dullness
and transversal heart distance
border Till 2 years 2-7 years 7-12 years Above 12 years

Right The right Inwards from the In the middle lines, closer to
parasternal line right side between the right the latter, after
parasternal line parasternal and some years-right
right sternal line parasternal line

Upper II rib II intercostal III rib III rib or III

space intercostal space
left 2 cm outwards 1 cm outwards 0,5 cm outward On the left
from left from left from mediaclavicle line
mediaclavicule mediaclavicule mediaclavicle line or 0,5 cm
line line inwards

Transversal heart 6-9 cm 8-12 cm 9-14 9-14

distance
 Borders of absolute heart dullness
and transversal heart distance
Right Left sternal line Left sternal line Left sternal line Left sternal
line

Upper II intercostal space III rib III intercostal space IV rib

left Closer to the left On the left Closer to the left Left parasternal
medioclavicular medioclavicular parasternalline line
(outside) line (outside)

Transversal 2-3 cm 4 cm 5-5,5 5-5,5

heart distance
Auscultation of heart
 Parameters of heart auscultation
 Characteristic I & II sound in all point
of auscultation (in normally clear and
rhythmic)
 Splitting of heart sound
 Clicks
 Snaps
 Characteristic of murmurs
 First (I) –
Apex beat – mitral valve
Second(II) - second intercostal
space to the right of sternum –
aortal valves
Third (III)– second intercostal
space to the left of sternum
pulmonary valves
Fourth (IV) –
Place of connection of
xiphosternum to sternum, little
to the right
tricuspid valve
Fifth (V) – place of
joining III –IV left ribs
to edge of sternum
mitral and aortal
valves
 S1
Include some components:
Valvular - vibrations caused
due to closing of bi- and
tricuspid valves; opening of
aortal and pulmonary valves
Muscular – the contraction of
muscles of ventricles
Vascular – vibrations of aortal
walls and pulmonary arteries
Atrial – the pressure of atrium
muscles
 S1=M1+T1
The sound produced by the
closure of the
mitral valve is termed M1 and
the sound
produced by closure of the
tricuspid valve is termed T1.
 split S1 heart sound
This occurs when the
mitral valve closes
significantly early than
tricuspid valve
allowing both valves to
make an audible,
separate sound.
S2- is valve
component –closing
and pressure of
semilunare valves of
aorta (A2) and
pulmonary arteries
(P2)
 Physiologic Split S2
Splitting S2 is heard during
inspiration
During inspiration venous
return to the right side of the
heart increases. It leads to
delays the closure of the
pulmonic valve
During expiration, the distance
narrows and the split S2 is no
longer audible.
 paradoxical split S2
Splitting S2 is heard during
expiration and disappears
during inspiration, the
opposite of the physiologic
split S2.
A paradoxical split S2 occurs
in any setting that delays the
closure of the aortic valve,
such
as severe aortic stenosis,
hypertrophic obstructive
cardiomyopathy (HOCM) or in
the setting of a left bundle
branch block (LBBB).
 Widened split S2
Widened splitting occurs
when both A2 and P2 are
audible (split) during the
entire respiratory cycle,
however the splitting
becomes greater with
inspiration (due to
increased venous return)
and less prominent with
expiration.
 Fixed split S2
A fixed split S2 occurs when
delay in the closure of the
pulmonic valve presents during
entire respiratory cycle
and there is no further
changing it during
inspiration (compare this to a
widened split S2 as described
above).
A fixed split S2 is
pathogneumonic for the
presence of an atrial septal
defect (ASD)
The third heart sound (S3),
also known as the S3 sound
"ventricular gallop", occurs
just after S2 when the
mitral valve opens allowing
passive filling of the left
ventricle.
The S3 sound is actually
produced by the large
amount of blood striking a
very compliant left
ventricle.
A S3 can be a normal
finding in children,
pregnant females, and well
trained athletes,
 S3 Sound
Third sounds are normal in
children with hyperdynamic circulations and
thin chest walls
pregnant females, and well trained athletes

but are usually abnormal in patients older than 30

years of age
S3 Sound
A S3 can be an
important sign of
systolic heart failure,
since in this setting
the myocardium is
usually overly
compliant resulting in
a dilated LV
 S4 sound
The fourth heart sound
(S4), also known as the
"atrial gallop", occurs just
before S1 when the atria
contract to force blood
into the LV.
S4- in children who go for
sports, connected with
atrial contraction
 S4
A S4 heart sound can be an important sign of
diastolic heart failure or active ischemia and is
rarely a normal finding.
Diastolic heart failure frequently results from
severe left ventricular hypertrophy (LVH)
resulting in impaired relxation (compliance) of
the LV. In this setting, a S4 is often heard.
Also, if a person is actively having myocardial
ischemia, adequate ATP can't be synthesized to
allow for the release of myosin from actin, thus
the myocardium is not able to relax and a S4 will
be present.
 Loudness of heard S1&S2 sound
depends of their age
Point I
2-3 days of life S2 > S1 in
After 2-3 months – S1 >S2
Points II & III
1 years life – S1 > S2
1-3 years may be S1=S2
After 3 years – S1< S2
 2-12 years
S2 over pulmonary artery > S2 over
aorta (amplification S2 over pulmonary
artery)
After 12 yeas
S2 over pulmonary artery = S2 over
aorta
 Soft Heart sound
(of noncardiac origin)
Obesity
Edema of thorax
Emphysema of lungs
Cardiac origin
LBBB (Left Bundle Branch Block )
Myocarditis
Pericardial effusion
Severy mitral stenosis
 Soft S1 sound on apex
Mitral insufficiency (the cusps are not
able to close completely)
Mitral valves stenosis (decreases of
mobility of valves
Weakening of S2 over aorta
Aortic valves stenosis
 Loud of the both heard sound
at healthy heard during
Emotional excitation
Physical exercise
Thin chest wall
Cardiac origin
Mild mitral stenosis
short PR interval
 Soft S1
Long PR interval
Severy mitral stenosis
LBBB (Left Bundle Branch Block )
СOPD(Chronic Obstructive Pulmonary 
Disease )
Obesity
Pericardial effusion
 Aortic ejection click
Loud high frequency
sound, associated with
murmur due to same
etiology
Best heard at apex Does not
vary with respiration
Causes associated with aortic
valve with decreased but some
residual mobility: i.e., aortic
stenosis, bicuspid aortic valves
and dilated aortic root; not
generally heard with
calcific aortic stenosis due to
non-mobile valve
 Pulmonic ejection click

Early systolic ejection sound with

associated murmur.
Often diminishes with inspiration.
Location:
Sternal edge 2nd or 3rd ICS
Clinical significance:
Causes associated with pulmonic valve:
pulmonic stenosis, pulmonary
hypertension and dilated pulmonary trunk
 Opening snap
 

High-frequency early diastolic

sound (occurs 50-100 msec
after A2) associated with mitral
stenosis ;.

Often diminishes with

inspiration' accentuated in left
lateral position.
Location: Between apex and left
lower sternal border
,
 Mid-systolic click
Mid-systolic click
(plus late systolic
murmur of mitral
valve prolapse)
FIGURE 1.
Listening areas for clicks:
upper right sternal border
(URSB) for aortic valve
clicks;
upper left sternal border
(ULSB) for pulmonary
valve clicks;
lower left sternal border
(LLSB), or the tricuspid
area, for ventricular
septal defects; apex for
aortic or mitral valve
clicks.
Murmurs

Murmurs are additional sounds

generated by turbulent blood flow
in the heart and blood vessels.
 Intensity/pitch
The intensity of a murmur is primarily
determined by the quantity and velocity of
blood flow at the site of its origin

In general, the intensity declines in the

presence of obesity, emphysema, and
pericardial effusion.
Murmurs are usually louder in children
and in thin individuals.
 GRADES

Systolic murmurs are graded on a six-point scale.

grade 1 murmur is barely audible
grade 2 murmur is louder and
grade 3 murmur is loud but not accompanied by a thrill.
grade 4 murmur is loud and associated with a palpable
thrill
grade 5 murmur is associated with a thrill, and the murmur
can be heard with the stethoscope partially off the chest.
Finally the grade 6 murmur is audible without a
stethoscope.

All murmurs louder than grade 3 are pathologic.

Configuration — A
number of configurations
or shapes of murmurs
are recognized:

  •  Crescendo
(increasing)
  •  Decrescendo
(diminishing)
  •  Crescendo-
decrescendo
(increasing-decreasing
or diamond shaped)
  •  Plateau (unchanged
in intensity)
 Quality 
The quality of a murmur can be described as harsh,
rumbling,
scratchy,
grunting,
blowing,
squeaky,
and musical.
The quality of a murmur may also change and, if
recognized, can be helpful in the diagnosis of an anomaly.
Many functional or innocent murmurs are
“vibratory” or “musical” in quality.
Still's murmur is the innocent murmur most
frequently encountered in children. This
murmur is usually vibratory or musical.
 Radiation
The direction of radiation of a murmur follows the
direction of blood flow. It can provide information
regarding the origin of the murmur.

For example, the murmur of aortic stenosis

frequently radiates to the carotid arteries
and themurmur of mitral regurgitation radiates to
the left axillary region.
The character, or tone of a murmur,
A “harsh” murmur is consistent with high-
velocity blood flow from a higher pressure to a
lower pressure. “Harsh” is often appropriate for
describing the murmur in patients with
significant semilunar valve stenosis or a
ventricular septal defect.
“Whooping” or “blowing” murmurs at the apex occur
with mitral valve regurgitation. The term “flow
murmur” is often used to describe a
crescendo/decrescendo murmur that is heard in
patients with a functional murmur 
However, similar systolic ejection murmurs may be
heard in patients with atrial septal defect, mild
semilunar valve stenosis, subaortic obstruction,
coarctation of the aorta or some very large
ventricular septal defects.
 Duration
 The duration of a murmur is assessed by
determining the length of systole or
diastole that the murmur occupies.
The murmur can be long (eg, it occupies
most of systole or diastole),
or it can be brief.
 Timing 
The timing of the
relation to the
cardiac cycle is the i
nitial step in identifying
the cause and
significance of the
murmur

 
 Systolic murmurs
A systolic murmur starts with or after S1 and
terminates before or at S2
Systolic murmurs are recognized by
identifying S1 and S2 and timing them with
the carotid pulse.
 Systolic murmurs
  •  An ejection systolic murmur
(midsystolic) begins after the S1 and
ends before A2 (left sided) or P2
(right sided)

  •  A holosystolic murmur starts with

S1 and extends up to A2 (left sided)
or P2 (right sided)

  •  An early systolic murmur starts with

S1 and extends for a variable length
in systole but does not extend up to
S2

  •  A late systolic murmur starts after

S1 and extends to A2 (left sided) or
P2 (right sided)
An early systolic murmur
starts with S1 and
extends for a variable
length in systole but
does not extend up to S2

  •  A late systolic

murmur starts after S1
and extends to A2 (left
sided) or P2 (right sided)
 Diastolic murmurs
A diastolic murmur starts with or after S2 and
ends at or before S1.
Diastolic murmurs are also classified according to
the time of onset and termination of the murmur
in diastole:

  •  
 Diastolic murmurs
 are usually abnormal, and may be early, mid or
late diastolic.
Early diastolic murmurs immediately follow S2.
Examples: aortic and pulmonary regurgitation.
Mid-diastolic murmurs due to increased flow
through the mitral or the tricuspid valves.
Examples: VSD and ASD.
Late diastolic murmurs due to pathological
narrowing of the AV valves.
Example: rheumatic mitral stenosis
Early
diastolic murmurs
immediately follow S2
Examples: aortic and
pulmonary
regurgitation.
Mid-diastolic murmurs
due to increased flow
through the mitral or
the tricuspid valves
Examples: VSD and
ASD
PSM is a high-frequency
 crescendo murmurthat 
extends into S1 and
results from
pathological narrowing
of the AV valves.
Example: rheumatic
mitral stenosis
 Continuous murmur
Continuous murmurs are present during both
systole and diastole.
Examples: patent ductus arteriosus (PDA) and
systemic arterio-venous fistulae.
 Systolic Murmurs in children
 are the most common
Holosystolic (regurgitant) murmurs start at the beginning of S1
and continue to S2.
Examples: ventricular septal defect (VSD), mitral valve
regurgitation, tricuspid valve regurgitation.

Systolic ejection murmurs (SEM, crescendo-decrescendo)

result from turbulent blood flow across the aortic and
pulmonary valves.
Blood flow across these valves starts after adequate pressure
has built up in the ventricle to overcome the pressure in the
aorta or pulmonary artery.
Examples: aortic and pulmonary stenosis. A murmur with
similar characteristics may be heard in coarctation of the
aorta.
 Innocent murmur
Innocent heart murmurs are sounds made
by the blood circulating through the heart's
chambers and valves or through blood
vessels near the heart. They're sometimes
called other names such as "functional" or
"physiologic" murmurs.

 Systolic Early, short duration murmur, increases with

inspiration.
 Characteristics
of innoset murmur
Soft, less than 3/6 in intensity (although note that even when
structural heart disease is present, intensity does not predict
severity.)
Often position-dependent. Murmurs heard while supine and
may disappear when upright or sitting
Otherwise healthy individual, no concerns about growth, no
symptoms of heart failure such as dyspnea on exertion.
Occurs during systole or continuously during both systole and
diastole. (Murmurs occurring only during diastole are always
pathologic.)
Physiologic splitting of S2 (A2 and P2 components should only
be resolvable during inspiration and should merge during
expiration.)
No palpable thrill (A thrill is a vibration caused by turbulent
blood flow.
 Still’s murmurs.
 These murmurs are low-pitched sounds heard at
the lower left sternal area.
They are musical or have a relatively pure tone in
quality or may be squeaky.
These most commonly occur between age 3 and
adolescence. Because they are low pitched, they
are heard best with the bell of the stethoscope.
They are related to flow, and they can change with
position alteration and then can decrease or
disappear with the Valsalva maneuver. No clicks
are present.
 Pulmonary flow murmurs.
high-pitched,harsher murmurs heard at the upper left sternal
border.
Because they are high pitched, they are heard best with the
diaphragm of the stethoscope.
They are flow dependent and also will change with position
alteration and decrease or disappear with the Valsalva
maneuver.
These murmurs originate from the right ventricular outflow tract
and radiate along the pulmonary arteries and thus may be well
heard in the back and axilla bilaterally.
They are differentiated from pulmonic stenosis by their quality
and from valvar pulmonic stenosis by the absence of an
ejection click.
Pulmonary flow murmurs can occur at any age, but they are
common particularly in adolescents or in children with pectus
excavatum.
 Systemic flow murmurs
(supraclavicular systemic bruits). These are harsh high-
pitched murmurs caused by normal blood flow into the
aorta and into the head and neck vessels and are heard
best high up in the chest and above the clavicles.
They are also heard best with the diaphragm of the
stethoscope.
No ejection click is associated with these murmurs.
They are transmitted to the arch vessels and are heard
when listening over the carotid arteries of the neck.
It has been said that because of these sounds “all children
have carotid bruits”; however, the sounds differ in quality
from true carotid bruits and are not associated with aortic
outflow pathology.
 Venous hums.
These are low-pitched continuous murmurs made by
blood returning from the great veins to the heart.
They are heard best with the bell of the stethoscope. By
changing the position of the patient’s head or by pressing in
the area of the major neck veins, the flow may be changed
and these murmurs will change or disappear.
Having the child look down or to the side while listening will
often make these murmurs or sounds disappear.
They are differentiated from the murmurs of patent ductus
arteriosus in that they are louder in diastole, when maximal
flow occurs in the venous system, and are often heard
bilaterally.
Venous hums are sensitive to posture and head and neck
position, whereas the murmur of patent ductus is not
 Mitral valve prolapse
produces a mid-systolic
click usually followed by
a uniform, high-pitched
murmur.
The murmur is actually
due to mitral
regurgitation that
accompanies the MVP,
thus it is heard best at
the cardiac apex. MVP
responds to dynamic
auscultation.
Murmur in Congenital heart
Disesases
 Atrial septal defect (ASD)
The S2 in fixed-split in a person
with an ASD. This differs from
The murmur produced by an ASD the widened split S2 seen in
is due to increased flow through severe PS. Also, the murmur of
the pulmonic valve, thus it is an ASD does not increase in
remarkably similar to that of intensity with inspiration.
pulmonic stenosis.
he difference lies in the intensity
and splitting pattern of the S2
heart sound.
he intensity of S2 should remain
unchanged and may infact be
accentuated if pulmonary
hypertension develops.
 Aortic stenosis
Murmur:
Harsh late-peaking
crescendo-decrescendo
systolic murmur
Heard best- left 2nd ICS
Radiation to the carotids.
Possible associated findings:
Abnormal carotid pulse
Diminished and delayed
("pulsus parvus and tardus")
Sustained Apical impulse
Calcified aortic valve on CXR
 Mitral Regurgitation:
Murmur:
Blowing holosystolic
murmur
Heard best at the apex
Radiation to the axilla
and inferior edge of left
scapula.
Possible associated
findings:
S2: wide physiologic
splitting
S3
 Aortic insufficiency:
Murmur:
Soft blowing early diastolic decrescendo murmur
Heard best at the left 2nd ICS without radiation
May also hear systolic flow murmur and
diastolic rumble (Austin Flint)
Possible associated findings:
Dilated apical impulse
Abnormal and collapsing arterial pulses
 Tricuspid regurgitation
Murmur:
Soft holosystolic murmur
Heard best at the LLSB
without radiation
Intensity increases with
inspiration or pressure over
liver
Possible associated findings:
Elevated neck veins
Systolic regurgitant neck vein
Systolic retraction of apical
pulse
Edema, Ascites or both
 Pulmonic Insufficiency
Murmur:
High frequency early diastolic decrescendo
murmur
Heard best at 2nd-3rd ICS
Increases with inspiration
Associated findings:
Abnormal S2 splitting
Sustained pulmonary hypertension
 Pulmonary stenosis
Murmur:
Harsh crescendo-
decrescendo systolic murmur
Heard best sternal border bat
2nd or 3rd intercostal spaces
Increases with inspiration
Associated findings:
Ejection sounds heard at
sternal edge, 2nd or 3rd
intercostal space
Wide physiological splitting
of S2
Prominent A wave of the
jugular venous pulse
 Mitral stenosis
Murmur:
Low frequency rumbling mid-diastolic murmur,
with presystolic component possible
Heard best at apex
Accentuated in left lateral decubitus position
Associated findings:
Apical impulse absent or small
Irregular pulse ( atrial fibrillation)
Loud S1
Elevated neck veins with exaggerated A wave
 Hypertrophic cardiomyopathy
Murmur:
Harsh quality midsystolic
murmur
Heard best LSB
Increases with decreased
venous return
Possible associated findings:
Sustained apical beat to
palpation
S4 (50% of the time)