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Heart Murmur in Infancy Cao Viet Tung MD National Hospital of Pediatrics Cardiovascular Examination l l History Physical Examination Inspection n Palpation n Auscultation n l Noninvasive studies HISTORY l l l l l l When was the murmur first detected? What were the circumstances? Signs/Symptoms/Review of Systems Perinatal history Medical history Family history Physical Exam: INSPECTION l l l l l l l Vital signs (BP, HR, RR, & SaO2) General state of health/nutrition Degree of comfort/activity level Skin: pallor, cyanosis, clubbing, edema? Respiratory effort/pattern Shape of chest and precordial activity Dysmorphic features Physical Exam: PALPATION l Pulses - radial, brachial, & femoral rate n rhythm n volume n character n l l Precordium/suprasternal notch Liver/spleen/thyroid Auscultatory Areas A P T M Auscultatory Findings l l l Rate Rhythm Heart Sounds 1st, 2nd, 3rd, and 4th n clicks n rubs n l Murmurs (systolic and diastolic) HEART SOUNDS l 1st Heart Sound (S1) n l AV valve closure 2nd Heart Sound (S2) n Semilunar valve closure HEART SOUNDS l 3rd Heart Sound (S3) n l Rapid ventricular filling 4th Heart Sound (S4) n Ventricular filling with atrial contraction Characteristics of a Heart Murmur l l l l l Intensity Timing Frequency Location and Radiation Variation with Position/Maneuvers INTENSITY l l l l l l Grade I = barely audible Grade II = easily heard Grade III = moderately loud Grade IV = loud with thrill Grade V = with steth edge on chest Grade VI = with steth off chest Factors Effecting Intensity l l l l l Fever Anemia Exercise CHF Position/Maneuvers TIMING Relationship to S1 and S2 l Systolic Ejection Murmur (SEM) S1 S2 TIMING Relationship to S1 and S2 l Holosystolic/Pansystolic Murmur S1 S2 TIMING Relationship to S1 and S2 l Decrescendo Diastolic Murmur S1 S2 TIMING Relationship to S1 and S2 l Atrial Flow Murmur (Diastolic) S1 S2 S1 TIMING Relationship to S1 and S2 l Atrial Contraction Murmur (Diastolic) S1 S2 S1 TIMING Relationship to S1 and S2 l Continuous Murmur S1 S2 S1 Noninvasive Studies l Electrocardiogram l Chest X-Ray l Echocardiogram Common Normal Heart Murmurs Vibratory Systolic Murmur (Still’s) Pulmonary Flow Murmur Peripheral Pulmonary Stenosis Cervical Venous Hum Carotid Bruit/Supraclavicular Systolic Murmur Most Common Pathologic Murmurs Aortic Stenosis Pulmonary Stenosis Coarctation of the Aorta Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Most Common Pathologic Murmurs Patent Ductus Arteriosus (PDA) Tetralogy of Fallot (TOF) Mitral Insufficiency(regurgitation) Aortic Insufficiency (regurgitation) Congenitalsuspected Heart Defect a History, P/E b Chest film c ECG Patient acyanotic PBF LVH or Combined VSD PDA AVSD RVH ASD PAPVC Patient cyanotic PBF PBF normal LVH AS MR CoA d LVH or Combined RVH PS MS Truncus A Single V TGA/VSD – D Echo PBF RVH LVH RVH Combined Tricuspid A Hypo.RV TOF Ebstein’s TAPVC Hypo LV TGA TGA/PS Single V-PS Definitive diagnosis Heart murmur in Newborn infant History, P/E Grade intensity of murmur Grade 1~2 No CHF or cyanosis Innocent murmur Grade 3~6 CHF or cyanosis Serious anomaly Systolic ejection At birth Continuous Pt.2~3wks of age Pul Flow murmur Vibratory murmur Transient m of PDA TGA,TOF TAPVC, Hypo LV Hypo RV AS PS CoA VSD PDA