Murmurs

Dr. Kalpana Malla

MBBS MD (Pediatrics) Manipal Teaching Hospital

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Classification of CVS anomaly

1. Structural heart defects-cyanotic, acyanotic 2. Functional heart defects cong cardiac arrythmias 3. Positional heart defects - dextrocardia

Murmurs
Turbulence in blood flow at or near valve flow murmur An abnormal communication within heart shunt murmur Heart murmurs may be present without any heart disease

Types
1. Innocent or functional 2. Pathological or organic

INNOCENT MURMURS:
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Also known as flow, benign, non pathologic, functional, inorganic physiologic Occur in up to - 77% of neonates - 66% of children - 90% with exercise

What are Innocent Murmurs?

- Due to physiological turbulence of blood within normal anatomical heart - No structural cardiac Ds - No hemodynamic abnormalities - Become prominent fever, anxiety, anemia, infections

Character of IM
Systolic soft grade 2 ** exception venous hum continuous murmur No thrill Intensity variable change with posture Normal pulse Normal S2 Normal CXR & ECG

Pathologic murmurs
Associated with structural abnormalities of CVS Characteristics: Grade 3 or louder Thrill + Pansystolic ,diastolic Abnormal pulse Cardiac symptoms Abnormal ECG,CXR

Systolic Murmurs
1. Holosystolic /Pansystolic - MR
- TR - VSD

Systolic Murmurs
2. Ejection systolic (Midsystolic)

- Innocent M - Flow M all flow M in VSD,ASD,PDA

- Aortic valve sclerosis - Aortic outflow obstruction - Aortic stenosis 3. Late systolic M - MV prolapse - TV prolapse

Diastolic murmurs
Early diastolic M - Aortic Regurgitation - Pulmonary R Mid Diastolic M
MS TS Artial myxoma flow across AV valve Austin Flint M Carey- Coombs M

Diastolic murmurs
Late Diastolic M ( Presystolic M) - MS - TS

Continuous Murmurs
PDA Aorticopulmonary window Arteriovenous fistulas Venous hum

Nada s criteria:
MAJOR 1.Systolic murmur grade>3 2.Diastolic murmur 3.Cyanosis 4.CCF MINOR 1.Systolic murmur<3 2.Abnormal S2 3.Abnormal ECG 4.Abnormal x-ray 5.Abnormal BP

Diagnosis:
Presence of 1 major OR 2 minor criteria Nada s criteria for presence of heart disease

Innocent Murmurs of Childhood 1. Vibratory Still s murmur 2. Pulmonary flow murmur 3. Physiological pulmonary flow murmur of neonate 4. Carotid bruit 5. Venous hum 6. Apical murmur

Vibratory Still s Murmur

Most common innocent murmur of childhood Age 2 to 6 years, rare in teens Etiology unknown, may be associated with LV ejection

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Still s Murmur
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Location max at LLSB, LMSB Character vibratory, groaning, musical Radiation apex, Timing mid-systole Intensity grade I-II Pitch mid to low

Still s Murmur
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Variation Loudest - supine, after exercise, with fever, anemia, or excitement Disappears or localizes to LLSB when upright Normal ECG

2. Pulmonary Systolic Murmur:

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Age common 8-14 years Etiology normal ejection vibrations ,turbulence through PV Intensity mid systolic grade I-III Location - ULSB Pitch mid to high-pitched Character soft, blowing, somewhat grating, diamond-shaped

Pulmonary Systolic Murmur

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Variation louder when supine, fever, exercise, anemia D/D ASD PS Sub AS ToF

Physiological Pulmonary flow murmur of neonate

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Age newborns. May last 3 6 months Etiology p turbulence and relative obstruction at PA bifurcation due to acute angle at birth

Physiological Pulmonary flow murmur of neonate

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Location LUSB Radiation LMSB, bilateral axillae, midback Timing early to mid-systole

Physiologic PPS
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Intensity grade I-II Pitch high-pitched Character blowing, not harsh, diamondshaped Variation none

4. Carotid Bruit
Bruit is French for noise Age range children and young adults Etiology turbulence at take off of carotid or brachiocephalic vessels

Carotid Bruit (Characteristics):

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Location neck - suprasternal notch, supraclavicular areas Radiation carotids, below clavicles Timing early to mid-systole (grade I-III) Character may be slightly harsh Arise in carotid or subclavian arteries

Carotid Bruit
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Variation decreased intensity with hyperextension of shoulders; louder with anxiety, anemia, D/D Supravalvar or valvar AS CoA Bicuspid AoV

5. Venous Hum:
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Second most common innocent murmur Etiology turbulence in jugular and subclavian venous return meeting in SVC Age - pre-school Adololescents - can be + w/ increased blood flow states e.g. anemia, pregnancy, thyrotoxicosis

Venous Hum
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Location anterior neck to mid-infraclavicular area, R side > L side Radiation may go to LMSB Intensity grade I-III Pitch mid to low Character continuous ,soft, whispering, roaring, or blowing

Venous Hum
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Variation Disappears - supine position, - with gentle manual compression of jugular vein - with head turn AWAY from the side

Thank you
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