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Heart Murmur in Infancy
Cao Viet Tung MD
National Hospital of Pediatrics


Cardiovascular Examination
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History
Physical Examination
Inspection
n Palpation
n Auscultation
n

l

Noninvasive studies


HISTORY
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When was the murmur first detected?

What were the circumstances?
Signs/Symptoms/Review of Systems
Perinatal history
Medical history
Family history


Physical Exam: INSPECTION
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l

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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
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l
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Rate

Rhythm
Heart Sounds
1st, 2nd, 3rd, and 4th
n clicks
n rubs
n

l

Murmurs (systolic and diastolic)


HEART SOUNDS
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1st Heart Sound (S1)
n

l

AV valve closure

2nd Heart Sound (S2)
n

Semilunar valve closure


HEART SOUNDS
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3rd Heart Sound (S3)
n

l

Rapid ventricular filling

4th Heart Sound (S4)
n

Ventricular filling with atrial contraction


Characteristics of a
Heart Murmur
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Intensity
Timing
Frequency
Location and Radiation
Variation with Position/Maneuvers


INTENSITY

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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
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Fever
Anemia
Exercise
CHF
Position/Maneuvers

TIMING

Relationship to S1 and S2
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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
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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

2 – 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