This document discusses the differential diagnosis and approach to evaluating a heart murmur in a term infant less than 6 months old. It focuses on the most common structural lesions presenting with a murmur in this age group. Peripheral pulmonary stenosis is a common cause of innocent heart murmurs in term infants. Ventricular septal defects are the most common congenital heart defects identified in this age group. The presentation depends on defect size and pulmonary vascular resistance status. A thorough history, physical exam including vital signs, inspection, palpation, and auscultation of the heart in a systematic manner can help distinguish innocent from pathological murmurs.
Approach to cyanotic congenital heart diseaseikramdr01
This document provides guidance on diagnosing cyanotic congenital heart disease through a practical clinical approach. It emphasizes the importance of suspecting heart disease in any child who does not clearly fit the initial diagnosis or has significant desaturation. Key signs to look for include cyanosis, differential pulse oximetry readings, and clues from chest X-ray and ECG. The approach involves classifying heart defects based on hemodynamics like pulmonary blood flow and systemic saturation. For neonates, focus is on duct-dependent lesions presenting with cyanosis or shock. Beyond the neonatal period, diagnosis involves assessing cyanosis and pulmonary congestion to identify lesions like left-to-right shunts, tetralogy of Fallot physiology,
This document discusses ECG patterns in congenital heart disease. It begins by outlining the significance of ECG in diagnosing congenital heart defects. It then provides an overview of normal ECG changes in children and how they evolve over time as hemodynamics change. Next, it describes how ECG can help identify situs and ventricular position. It then discusses the characteristic ECG patterns seen in common acyanotic defects like atrial septal defects and ventricular septal defects. It also covers cyanotic defects like transposition of the great arteries. The document provides detailed information on ECG features, associated conditions, complications and evolution over time for many different congenital heart defects.
This document discusses different types of heart murmurs, including innocent or benign murmurs versus pathological murmurs. It provides details on specific murmurs such as Still's murmur, pulmonary flow murmur, physiological pulmonary flow murmur in neonates, carotid bruit, and venous hum. Characteristics of different systolic, diastolic, and continuous murmurs are outlined. Nada's criteria for diagnosing the presence of heart disease is also summarized.
This document provides information on the approach and assessment of acyanotic congenital heart diseases in children. It discusses:
1. The typical presenting complaints which include feeding difficulties, respiratory distress, easy fatigability, recurrent infections, and failure to thrive.
2. The physical exam findings to assess including inspection, palpation of pulses, blood pressure, jugular venous pressure, auscultation of heart sounds and murmurs.
3. The classification of acyanotic heart diseases which include left-to-right shunts and outflow obstructions. The most common types are also listed.
This document discusses supraventricular tachycardia (SVT) in pediatric patients. SVT is the most common abnormal heart rhythm seen in children and the most common arrhythmia requiring treatment. It is usually caused by re-entry mechanisms involving an accessory pathway or the atrioventricular node. Diagnosis involves obtaining an electrocardiogram during episodes to identify P wave patterns. Treatment options include vagal maneuvers, medications like adenosine, calcium channel blockers, or beta blockers, and cardioversion. Radiofrequency ablation can provide a cure for refractory or recurrent cases. Proper diagnosis of the underlying SVT mechanism guides selection of the most appropriate treatment approach.
This document discusses the use of ECG in pediatric practice. It begins with an overview of ECG from neonates to adolescents and how it changes with age. It then covers normal ECG patterns in neonates, infants, children and adolescents. The rest of the document details age-related ECG changes and describes ECG patterns that can help identify common congenital heart defects such as VSD, ASD, TOF and others. It emphasizes that ECG provides valuable clues for diagnosis in cyanotic children and is invaluable for assessing arrhythmias and pre-surgical planning.
This document discusses pediatric cardiac arrhythmias. Some key points:
- Arrhythmias are classified based on site of origin such as the sinus node, atria, AV node or ventricles. Common arrhythmias include sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia.
- Presentation of arrhythmias in children varies by age. Neonates may experience atrial flutter or ectopic atrial tachycardia. Older children may experience WPW syndrome or AV nodal re-entrant tachycardia.
- Diagnosis involves analyzing the ECG for heart rate, QRS width, and P wave relationship to the
This document provides an overview of segmental analysis for congenital heart disease. It discusses the key segments that are analyzed which include thoraco-abdominal situs, pulmonary situs, atrial situs, ventricular situs and looping, connections between segments (venous, atrioventricular, ventriculoarterial), and abnormalities that can occur in each segment. The document emphasizes evaluating each segment in a systematic, sequential manner to identify abnormalities.
Approach to cyanotic congenital heart diseaseikramdr01
This document provides guidance on diagnosing cyanotic congenital heart disease through a practical clinical approach. It emphasizes the importance of suspecting heart disease in any child who does not clearly fit the initial diagnosis or has significant desaturation. Key signs to look for include cyanosis, differential pulse oximetry readings, and clues from chest X-ray and ECG. The approach involves classifying heart defects based on hemodynamics like pulmonary blood flow and systemic saturation. For neonates, focus is on duct-dependent lesions presenting with cyanosis or shock. Beyond the neonatal period, diagnosis involves assessing cyanosis and pulmonary congestion to identify lesions like left-to-right shunts, tetralogy of Fallot physiology,
This document discusses ECG patterns in congenital heart disease. It begins by outlining the significance of ECG in diagnosing congenital heart defects. It then provides an overview of normal ECG changes in children and how they evolve over time as hemodynamics change. Next, it describes how ECG can help identify situs and ventricular position. It then discusses the characteristic ECG patterns seen in common acyanotic defects like atrial septal defects and ventricular septal defects. It also covers cyanotic defects like transposition of the great arteries. The document provides detailed information on ECG features, associated conditions, complications and evolution over time for many different congenital heart defects.
This document discusses different types of heart murmurs, including innocent or benign murmurs versus pathological murmurs. It provides details on specific murmurs such as Still's murmur, pulmonary flow murmur, physiological pulmonary flow murmur in neonates, carotid bruit, and venous hum. Characteristics of different systolic, diastolic, and continuous murmurs are outlined. Nada's criteria for diagnosing the presence of heart disease is also summarized.
This document provides information on the approach and assessment of acyanotic congenital heart diseases in children. It discusses:
1. The typical presenting complaints which include feeding difficulties, respiratory distress, easy fatigability, recurrent infections, and failure to thrive.
2. The physical exam findings to assess including inspection, palpation of pulses, blood pressure, jugular venous pressure, auscultation of heart sounds and murmurs.
3. The classification of acyanotic heart diseases which include left-to-right shunts and outflow obstructions. The most common types are also listed.
This document discusses supraventricular tachycardia (SVT) in pediatric patients. SVT is the most common abnormal heart rhythm seen in children and the most common arrhythmia requiring treatment. It is usually caused by re-entry mechanisms involving an accessory pathway or the atrioventricular node. Diagnosis involves obtaining an electrocardiogram during episodes to identify P wave patterns. Treatment options include vagal maneuvers, medications like adenosine, calcium channel blockers, or beta blockers, and cardioversion. Radiofrequency ablation can provide a cure for refractory or recurrent cases. Proper diagnosis of the underlying SVT mechanism guides selection of the most appropriate treatment approach.
This document discusses the use of ECG in pediatric practice. It begins with an overview of ECG from neonates to adolescents and how it changes with age. It then covers normal ECG patterns in neonates, infants, children and adolescents. The rest of the document details age-related ECG changes and describes ECG patterns that can help identify common congenital heart defects such as VSD, ASD, TOF and others. It emphasizes that ECG provides valuable clues for diagnosis in cyanotic children and is invaluable for assessing arrhythmias and pre-surgical planning.
This document discusses pediatric cardiac arrhythmias. Some key points:
- Arrhythmias are classified based on site of origin such as the sinus node, atria, AV node or ventricles. Common arrhythmias include sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia.
- Presentation of arrhythmias in children varies by age. Neonates may experience atrial flutter or ectopic atrial tachycardia. Older children may experience WPW syndrome or AV nodal re-entrant tachycardia.
- Diagnosis involves analyzing the ECG for heart rate, QRS width, and P wave relationship to the
This document provides an overview of segmental analysis for congenital heart disease. It discusses the key segments that are analyzed which include thoraco-abdominal situs, pulmonary situs, atrial situs, ventricular situs and looping, connections between segments (venous, atrioventricular, ventriculoarterial), and abnormalities that can occur in each segment. The document emphasizes evaluating each segment in a systematic, sequential manner to identify abnormalities.
This document discusses ductus arteriosus dependent congenital heart diseases. It begins by defining ductus dependent circulation as abnormalities where ductus arteriosus patency is required to maintain systemic perfusion. It then describes the anatomy and physiology of the ductus arteriosus, noting its role in diverting blood from the pulmonary to systemic circulation in fetal life. The document outlines conditions of ductus dependent pulmonary and systemic blood flow. It discusses goals of management as minimizing hypoxemia and balancing pulmonary and systemic circulations. Maintaining ductal patency with prostaglandins is emphasized as critical for stabilization in ductus dependent lesions.
Paediatric Congenital Heart Defects Case PresentationSCGH ED CME
A 12 week old girl presented with increased work of breathing and poor feeding. On examination, she was tachycardic, hypoxic, and floppy with crackles and a murmur.
Initial investigations showed severe metabolic acidosis and hyperkalemia. Echocardiogram revealed congenital mitral regurgitation, severe mitral regurgitation, and multiorgan failure.
She was diagnosed with congenital mitral regurgitation and shock from cardiac decompensation, precipitated by rhinovirus infection. She required intensive care management including ventilation, fluid resuscitation, and inotropic support.
This document discusses cyanotic congenital heart disease (CCHD), which is defined as a cardiovascular birth defect that results in systemic arterial desaturation due to a right-to-left shunt. CCHDs can be classified based on pulmonary blood flow as having reduced, increased, or near normal flow. Common types of CCHDs with reduced pulmonary blood flow include tetralogy of Fallot and pulmonary atresia. CCHDs with increased pulmonary blood flow can present with features of congestive heart failure. The clinical approach to CCHDs involves delineating the anatomical and physiological abnormalities through assessment of anatomy, pulmonary circulation, systemic circulation, and ventricular function.
This document provides information on dextro-transposition of the great arteries (D-TGA), including that it accounts for 5-7% of congenital heart defects and has a 3:1 male to female ratio. Half of D-TGA cases have no other associated defects besides a PFO or PDA. The document discusses the anatomy of D-TGA, associated defects like VSD that can occur, natural history, clinical features, investigations including echocardiography views, management approaches both medically and surgically, and complications. Key surgical procedures mentioned are arterial switch operation, Rastelli procedure, and atrial level switch.
This document discusses the management of patients with duct dependent circulation. It describes various cardiac conditions that rely on the ductus arteriosus remaining patent, such as pulmonary atresia. It outlines signs that should prompt consideration of duct dependency, like cyanosis or shock. The use of prostaglandin E1 infusion to maintain ductal patency is described in detail, including monitoring for side effects and adjusting the infusion rate based on clinical response. Other options to ensure mixing of blood or keep shunts open such as atrial septostomy or valvuloplasty are mentioned. The importance of recognizing duct dependency and starting prostaglandin treatment promptly when indicated is emphasized.
CYANOTIC CONGENITAL HEART DISEASES WITH DECREASED BLOOD FLOWbadrik19
This document discusses cyanosis and its causes in neonates. It begins by defining cyanosis as a bluish tinge of the skin and mucous membranes, detectable when hemoglobin is reduced by more than 5g% or oxygen saturation is below 85%. It then lists various pulmonary, cardiac, central nervous system, metabolic, hematologic, and infectious conditions that can cause cyanosis in newborns. The majority of the document focuses on describing tetralogy of Fallot, including its characteristic features, pathophysiology, clinical presentation, diagnosis, and management. It provides details on the anatomy, causes, hypoxic spells, and treatment approaches for tetralogy of Fallot.
1) Complete transposition of the great arteries (d-TGA) is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, causing ventriculoarterial discordance.
2) In d-TGA, the systemic and pulmonary circulations are arranged in parallel rather than in series, requiring blood flow between the circuits through connections like an atrial or ventricular septal defect.
3) Echocardiography is useful for diagnosing d-TGA by demonstrating the aorta originating from the right ventricle and pulmonary artery from the left ventricle, as well as identifying the origins of the coronary arteries.
Approach to cardiac murmurs and cardiac examination in childrenVarsha Shah
Cardiovascular examination in children for MBBS undergraduate, Residents, Trainees, pediatricians, GP, family physicians, nursing , dental, allied health students
Tetralogy of Fallot is the most common cyanotic heart disease characterized by four features: ventricular septal defect, overriding aorta, infundibular pulmonary stenosis, and right ventricular hypertrophy. It presents with cyanosis that is more frequent in the second half of the first year and hypercyanotic spells after exercise or positions like crying and squatting. Treatment involves palliative surgery like Blalock-Taussig shunt initially, followed by complete repair around 6 months of age. Management of hypercyanotic spells includes medications like morphine, oxygen, and positioning changes.
Approach to child with congenital heart diseaseAnkur Puri
This document provides guidance on evaluating a child with congenital heart disease. It outlines key questions to answer, including whether the condition is cyanotic or acyanotic. A thorough history is important, including prenatal, natal, and postnatal details. A physical exam involves assessing vital signs, growth, precordial examination, palpation of pulses and thrills, and auscultation of heart sounds and murmurs. The goal is to characterize the nature and severity of the congenital heart condition.
1. The pediatric ECG document reviews cardiac physiology and ECG findings in children of different ages. It discusses how the size of the ventricles changes from birth through childhood and how this impacts ECG measurements.
2. Key aspects of the normal pediatric ECG are described, including typical heart rates, axis shifts, and "juvenile" T wave patterns. Common abnormalities seen in pediatric patients such as chamber enlargement, conduction abnormalities, and arrhythmias are also reviewed.
3. The document provides guidance on interpreting ECG findings and correlating them to possible diagnoses in children, taking into account how measurements may differ based on age. Examples of ECG strips are included to illustrate various normal and abnormal
Patent Ductus Arteroisus, PDA, Cardiology, Paediatrics, Pedicatrics, Critical Care, Emergency medicine, Medicine, Internal Medicine, MBBD, MD, India, CMC Vellore, Christian Medical College
The document discusses various pediatric arrhythmias including tachycardias and bradycardias. It provides details on normal heart rates at different ages and describes common supraventricular tachycardias like AV nodal reentrant tachycardia, accessory pathway mediated tachycardias. It also discusses idiopathic ventricular tachycardia and management strategies for different arrhythmias including medication and ablation. Congenital complete heart block is described along with its association with maternal autoimmune conditions.
This document discusses pediatric cardiology emergencies, dividing them into newborn emergencies and infant/childhood emergencies. Newborn emergencies include cyanosis caused by obstructive lesions like pulmonary atresia or abnormal circulations like transposition of the great arteries, treated with prostaglandins. Low cardiac output in newborns can be caused by left-sided obstructive lesions, muscle diseases, or heart rate problems and is treated with inotropes and afterload reduction. Infant/childhood emergencies include hypercyanotic spells in conditions like tetralogy of Fallot, congestive heart failure with different causes at different ages, and arrhythmias including supraventricular tachy
Presentation on basic principles of pediatric ecg with important examples: BY Dr. Nivedita Mishra (PGY2 PEDIATRICS, TRIBHUVAN UNIVERSITY TEACHING HOSPITAL,KATHMANDU,NEPAL)
This document discusses atrioventricular septal defects (AVSDs). It begins with epidemiology, noting a prevalence of 4-5% of congenital heart defects. It then covers embryology, anatomy, pathology, classification, clinical features, diagnosis and management. Key points include abnormal development of endocardial cushions leading to absence of AV septum and common atrioventricular valves. Clinical features include congestive heart failure in infancy. Diagnosis is made via echocardiogram showing absent AV septum. Surgical repair aims to close defects and preserve left AV valve competence.
Pulmonary hypertension in infants and children can be neonatal, cardiac-related, acquired, or idiopathic. The gold standard test to confirm pulmonary hypertension is cardiac catheterization. Current pharmacologic treatments target three pathways - the endothelin pathway, nitric oxide pathway, and prostacyclin pathway. Combination drug therapy and non-pharmacologic options like atrial septostomy may also be used, but pulmonary hypertension remains a challenging condition to treat in children.
The document discusses the second heart sound (S2), which represents the closure of the aortic and pulmonary valves at the end of systole. S2 is normally split into A2 and P2 sounds. The timing of A2 and P2 can provide information about cardiac function and pressures. Specifically, the document discusses:
1) The components of a normal S2 split, including the "hangout interval" between pressure crossover and valve closure.
2) Causes of abnormal S2 splitting patterns including expiratory, inspiratory, fixed, and paradoxical splitting.
3) How pulmonary pressures, conduction abnormalities, and valvular diseases can affect the timing and components of S2.
4)
This document provides an overview of pediatric cardiology for medical students. It discusses the fetal, transitional, and postnatal circulations and how congenital heart defects disrupt normal circulation. It describes left-to-right shunts like VSDs and PDA that cause left heart enlargement and right-to-left shunts like Tetralogy of Fallot that cause cyanosis. Obstructive lesions like critical aortic stenosis that require ductal flow are discussed. The physical exam findings for different defects are outlined along with innocent murmurs and hereditary cardiac conditions.
This document provides a differential diagnosis for various types of cardiac murmurs based on location and timing. It lists potential causes of early, mid, and late systolic murmurs at the apex, left parasternal area, pulmonary area, and aortic area. Causes include various valvular regurgitations and stenoses, septal defects, patent ductus arteriosus, coarctation of the aorta, and other structural issues. Diastolic murmurs are also differentiated based on timing and location, with listed potential causes like mitral stenosis, aortic regurgitation, and pulmonary regurgitation. The document serves as a guide for physicians to consider possible diagnoses when evaluating patients with cardiac murmurs.
This document discusses ductus arteriosus dependent congenital heart diseases. It begins by defining ductus dependent circulation as abnormalities where ductus arteriosus patency is required to maintain systemic perfusion. It then describes the anatomy and physiology of the ductus arteriosus, noting its role in diverting blood from the pulmonary to systemic circulation in fetal life. The document outlines conditions of ductus dependent pulmonary and systemic blood flow. It discusses goals of management as minimizing hypoxemia and balancing pulmonary and systemic circulations. Maintaining ductal patency with prostaglandins is emphasized as critical for stabilization in ductus dependent lesions.
Paediatric Congenital Heart Defects Case PresentationSCGH ED CME
A 12 week old girl presented with increased work of breathing and poor feeding. On examination, she was tachycardic, hypoxic, and floppy with crackles and a murmur.
Initial investigations showed severe metabolic acidosis and hyperkalemia. Echocardiogram revealed congenital mitral regurgitation, severe mitral regurgitation, and multiorgan failure.
She was diagnosed with congenital mitral regurgitation and shock from cardiac decompensation, precipitated by rhinovirus infection. She required intensive care management including ventilation, fluid resuscitation, and inotropic support.
This document discusses cyanotic congenital heart disease (CCHD), which is defined as a cardiovascular birth defect that results in systemic arterial desaturation due to a right-to-left shunt. CCHDs can be classified based on pulmonary blood flow as having reduced, increased, or near normal flow. Common types of CCHDs with reduced pulmonary blood flow include tetralogy of Fallot and pulmonary atresia. CCHDs with increased pulmonary blood flow can present with features of congestive heart failure. The clinical approach to CCHDs involves delineating the anatomical and physiological abnormalities through assessment of anatomy, pulmonary circulation, systemic circulation, and ventricular function.
This document provides information on dextro-transposition of the great arteries (D-TGA), including that it accounts for 5-7% of congenital heart defects and has a 3:1 male to female ratio. Half of D-TGA cases have no other associated defects besides a PFO or PDA. The document discusses the anatomy of D-TGA, associated defects like VSD that can occur, natural history, clinical features, investigations including echocardiography views, management approaches both medically and surgically, and complications. Key surgical procedures mentioned are arterial switch operation, Rastelli procedure, and atrial level switch.
This document discusses the management of patients with duct dependent circulation. It describes various cardiac conditions that rely on the ductus arteriosus remaining patent, such as pulmonary atresia. It outlines signs that should prompt consideration of duct dependency, like cyanosis or shock. The use of prostaglandin E1 infusion to maintain ductal patency is described in detail, including monitoring for side effects and adjusting the infusion rate based on clinical response. Other options to ensure mixing of blood or keep shunts open such as atrial septostomy or valvuloplasty are mentioned. The importance of recognizing duct dependency and starting prostaglandin treatment promptly when indicated is emphasized.
CYANOTIC CONGENITAL HEART DISEASES WITH DECREASED BLOOD FLOWbadrik19
This document discusses cyanosis and its causes in neonates. It begins by defining cyanosis as a bluish tinge of the skin and mucous membranes, detectable when hemoglobin is reduced by more than 5g% or oxygen saturation is below 85%. It then lists various pulmonary, cardiac, central nervous system, metabolic, hematologic, and infectious conditions that can cause cyanosis in newborns. The majority of the document focuses on describing tetralogy of Fallot, including its characteristic features, pathophysiology, clinical presentation, diagnosis, and management. It provides details on the anatomy, causes, hypoxic spells, and treatment approaches for tetralogy of Fallot.
1) Complete transposition of the great arteries (d-TGA) is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, causing ventriculoarterial discordance.
2) In d-TGA, the systemic and pulmonary circulations are arranged in parallel rather than in series, requiring blood flow between the circuits through connections like an atrial or ventricular septal defect.
3) Echocardiography is useful for diagnosing d-TGA by demonstrating the aorta originating from the right ventricle and pulmonary artery from the left ventricle, as well as identifying the origins of the coronary arteries.
Approach to cardiac murmurs and cardiac examination in childrenVarsha Shah
Cardiovascular examination in children for MBBS undergraduate, Residents, Trainees, pediatricians, GP, family physicians, nursing , dental, allied health students
Tetralogy of Fallot is the most common cyanotic heart disease characterized by four features: ventricular septal defect, overriding aorta, infundibular pulmonary stenosis, and right ventricular hypertrophy. It presents with cyanosis that is more frequent in the second half of the first year and hypercyanotic spells after exercise or positions like crying and squatting. Treatment involves palliative surgery like Blalock-Taussig shunt initially, followed by complete repair around 6 months of age. Management of hypercyanotic spells includes medications like morphine, oxygen, and positioning changes.
Approach to child with congenital heart diseaseAnkur Puri
This document provides guidance on evaluating a child with congenital heart disease. It outlines key questions to answer, including whether the condition is cyanotic or acyanotic. A thorough history is important, including prenatal, natal, and postnatal details. A physical exam involves assessing vital signs, growth, precordial examination, palpation of pulses and thrills, and auscultation of heart sounds and murmurs. The goal is to characterize the nature and severity of the congenital heart condition.
1. The pediatric ECG document reviews cardiac physiology and ECG findings in children of different ages. It discusses how the size of the ventricles changes from birth through childhood and how this impacts ECG measurements.
2. Key aspects of the normal pediatric ECG are described, including typical heart rates, axis shifts, and "juvenile" T wave patterns. Common abnormalities seen in pediatric patients such as chamber enlargement, conduction abnormalities, and arrhythmias are also reviewed.
3. The document provides guidance on interpreting ECG findings and correlating them to possible diagnoses in children, taking into account how measurements may differ based on age. Examples of ECG strips are included to illustrate various normal and abnormal
Patent Ductus Arteroisus, PDA, Cardiology, Paediatrics, Pedicatrics, Critical Care, Emergency medicine, Medicine, Internal Medicine, MBBD, MD, India, CMC Vellore, Christian Medical College
The document discusses various pediatric arrhythmias including tachycardias and bradycardias. It provides details on normal heart rates at different ages and describes common supraventricular tachycardias like AV nodal reentrant tachycardia, accessory pathway mediated tachycardias. It also discusses idiopathic ventricular tachycardia and management strategies for different arrhythmias including medication and ablation. Congenital complete heart block is described along with its association with maternal autoimmune conditions.
This document discusses pediatric cardiology emergencies, dividing them into newborn emergencies and infant/childhood emergencies. Newborn emergencies include cyanosis caused by obstructive lesions like pulmonary atresia or abnormal circulations like transposition of the great arteries, treated with prostaglandins. Low cardiac output in newborns can be caused by left-sided obstructive lesions, muscle diseases, or heart rate problems and is treated with inotropes and afterload reduction. Infant/childhood emergencies include hypercyanotic spells in conditions like tetralogy of Fallot, congestive heart failure with different causes at different ages, and arrhythmias including supraventricular tachy
Presentation on basic principles of pediatric ecg with important examples: BY Dr. Nivedita Mishra (PGY2 PEDIATRICS, TRIBHUVAN UNIVERSITY TEACHING HOSPITAL,KATHMANDU,NEPAL)
This document discusses atrioventricular septal defects (AVSDs). It begins with epidemiology, noting a prevalence of 4-5% of congenital heart defects. It then covers embryology, anatomy, pathology, classification, clinical features, diagnosis and management. Key points include abnormal development of endocardial cushions leading to absence of AV septum and common atrioventricular valves. Clinical features include congestive heart failure in infancy. Diagnosis is made via echocardiogram showing absent AV septum. Surgical repair aims to close defects and preserve left AV valve competence.
Pulmonary hypertension in infants and children can be neonatal, cardiac-related, acquired, or idiopathic. The gold standard test to confirm pulmonary hypertension is cardiac catheterization. Current pharmacologic treatments target three pathways - the endothelin pathway, nitric oxide pathway, and prostacyclin pathway. Combination drug therapy and non-pharmacologic options like atrial septostomy may also be used, but pulmonary hypertension remains a challenging condition to treat in children.
The document discusses the second heart sound (S2), which represents the closure of the aortic and pulmonary valves at the end of systole. S2 is normally split into A2 and P2 sounds. The timing of A2 and P2 can provide information about cardiac function and pressures. Specifically, the document discusses:
1) The components of a normal S2 split, including the "hangout interval" between pressure crossover and valve closure.
2) Causes of abnormal S2 splitting patterns including expiratory, inspiratory, fixed, and paradoxical splitting.
3) How pulmonary pressures, conduction abnormalities, and valvular diseases can affect the timing and components of S2.
4)
This document provides an overview of pediatric cardiology for medical students. It discusses the fetal, transitional, and postnatal circulations and how congenital heart defects disrupt normal circulation. It describes left-to-right shunts like VSDs and PDA that cause left heart enlargement and right-to-left shunts like Tetralogy of Fallot that cause cyanosis. Obstructive lesions like critical aortic stenosis that require ductal flow are discussed. The physical exam findings for different defects are outlined along with innocent murmurs and hereditary cardiac conditions.
This document provides a differential diagnosis for various types of cardiac murmurs based on location and timing. It lists potential causes of early, mid, and late systolic murmurs at the apex, left parasternal area, pulmonary area, and aortic area. Causes include various valvular regurgitations and stenoses, septal defects, patent ductus arteriosus, coarctation of the aorta, and other structural issues. Diastolic murmurs are also differentiated based on timing and location, with listed potential causes like mitral stenosis, aortic regurgitation, and pulmonary regurgitation. The document serves as a guide for physicians to consider possible diagnoses when evaluating patients with cardiac murmurs.
This document provides an overview of different types of heart murmurs:
1. It describes systolic murmurs which occur during ventricular contraction and can be early, mid, or late systolic. Common causes are aortic stenosis, mitral regurgitation, and mitral valve prolapse.
2. It also describes diastolic murmurs which occur during ventricular relaxation and include early diastolic murmurs from aortic regurgitation and rumbling mid to late diastolic murmurs from mitral stenosis.
3. Continuous murmurs that begin in systole and continue into diastole are also discussed, along with how to characterize location and timing of different murmurs.
The document discusses heart sounds, describing the four main sounds - S1, S2, S3, and S4. S1 occurs with the closing of the atrioventricular valves, coinciding with the R wave of an ECG. S2 occurs with the closing of the semilunar valves, coinciding with the T wave. S3 occurs during rapid ventricular filling between the T and P waves. S4 occurs during atrial systole between the P wave and Q wave. Heart sounds provide diagnostic value for assessing cardiac diseases and can be studied using a stethoscope, microphone, or phonocardiogram.
The document discusses the assessment and management of various pediatric cardiac conditions, including normal cardiac anatomy and physiology, congenital heart defects such as ventricular septal defects and tetralogy of Fallot, and procedures like cardiac catheterization. Nursing interventions for conditions like congestive heart failure focus on managing fluid status, increasing cardiac output, and decreasing oxygen demand. Diagnostic tools include echocardiograms, electrocardiograms, chest x-rays, and cardiac catheterizations, which can be used for both diagnosis and interventional procedures.
1. This patient presented with periodic paralysis caused by both hyperthyroidism (thyrotoxic periodic paralysis) and renal tubular acidosis. The hyperthyroidism prevented symptoms from manifesting until after delivery when potassium levels dropped further.
2. The initial nerve conduction study showed demyelination likely due to the previous episode being treated as a demyelinating disease.
3. Going forward, the patient will need long-term management of their hyperthyroidism, renal tubular acidosis, and further evaluation for Sjogren's syndrome. Potassium and bicarbonate supplementation as well as thyroid medication will be required.
This document discusses electrocardiograms (ECGs), including how to properly record and evaluate them and how to diagnose cardiac conditions with the help of ECGs along with clinical findings. It provides guidance on evaluating features of ECGs like rates, intervals, axes, and rhythms. It emphasizes that ECGs should not be used alone for diagnosis and must be considered together with a patient's clinical presentation and history. It also presents several case studies of pediatric cardiac patients and asks the reader to make a diagnosis based on the ECG and clinical findings provided.
This document discusses heart sounds and murmurs. It explains that heart sounds are caused by the closing of the atrioventricular and semilunar valves, producing the first and second heart sounds. The location of these sounds depends on which valves are closing. Murmurs can be caused by various valvular lesions that interfere with normal blood flow, such as stenosis or regurgitation of the aortic, mitral, or pulmonary valves. The characteristics of murmurs provide clues to the underlying heart condition.
Quadriplegia is paralysis of both arms and legs caused by injury to the cervical spinal cord. Paraplegia is paralysis of the lower half of the body caused by injury to the thoracic, lumbar, or sacral spinal cord. Management of spinal cord injuries involves immobilization, medications like methylprednisolone, and surgery to stabilize the spine. Physical therapy focuses on range of motion, strengthening, pain management, and retraining bladder and bowel function to prevent complications like pressure sores. Functional electrical stimulation has also been used to facilitate walking.
This document provides guidance on performing a peripheral vascular examination, including examining the arms and legs to check for signs of vascular disease. It describes how to inspect and palpate pulses in the upper and lower limbs, listen for bruits, and perform additional tests like Buerger's angle test. The document also covers examining the venous system, including inspection for varicose veins, palpating for fascial defects, and tests like Trendelenburg's test to check for venous incompetence.
This document provides an overview of heart sounds and murmurs, including how to use a stethoscope to listen to the heart and identify normal and abnormal sounds. It describes the four main heart sounds (S1, S2, S3, S4), their timing in the cardiac cycle, and common causes of extra heart sounds or murmurs such as mitral regurgitation, aortic stenosis, and congestive heart failure. Listening locations are identified for different sounds and murmurs. Characteristics like timing, quality, and radiation are described to help differentiate normal versus pathological findings.
Tetralogy of Fallot is a congenital heart defect consisting of four abnormalities present at birth: a ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. It occurs in approximately 5 out of every 10,000 babies. The defects can cause cyanosis and problems with oxygen circulation. Surgical repair is usually performed to close the ventricular septal defect, widen the pulmonary valve and blood vessels, and allow normal blood flow and oxygen circulation. Long term follow up is important after surgery to monitor for potential complications like arrhythmias or residual defects.
Heart murmurs are common in children but may indicate structural heart disease. A thorough history and physical exam is necessary to evaluate murmurs. Historical elements that increase likelihood of pathology include family history of sudden cardiac death or congenital heart disease, prenatal exposures, and certain genetic disorders. The physical exam should assess vital signs, exercise capacity, signs of heart failure, and characterize the murmur. Red flags include holosystolic, loud (> grade 3), harsh murmurs or those with maximal intensity standing or at the upper left sternal border. Echocardiography is recommended for potentially pathologic murmurs or neonatal murmurs to definitively diagnose any structural heart disease.
Heart murmurs are common in children but may indicate structural heart disease. A thorough history and physical exam is necessary to evaluate murmurs. Historical elements suggesting pathology include family history of heart conditions, genetic disorders, or prenatal exposures. The exam should assess vital signs, exercise capacity, signs of heart failure, and characterize any murmurs heard. Red flags requiring pediatric cardiology referral include holosystolic, diastolic, or loud murmurs; abnormal heart sounds; or physical findings suggesting heart disease. Echocardiography can definitively diagnose structural issues.
Heart murmurs are common in children but may indicate structural heart disease. A thorough history and physical exam is necessary to evaluate murmurs. Historical elements that increase likelihood of pathology include family history of sudden cardiac death or congenital heart disease, prenatal exposures, and certain genetic disorders. The physical exam should assess vital signs, exercise capacity, signs of heart failure, and characterize the murmur. Red flags include holosystolic, loud (> grade 3), harsh murmurs or those with maximal intensity standing or at the upper left sternal border. Echocardiography is recommended for murmurs with concerning history or exam findings or when the cause cannot be determined to make a definitive diagnosis.
Dr. Nagendra Prasad provides an overview of acyanotic congenital heart diseases. He discusses that they present with signs of congestive heart failure and/or heart murmurs during infancy or early childhood. The most common presentations are feeding difficulties, tachypnea, sweating, subcostal recession, and recurrent respiratory infections. Echocardiography, ECG, chest x-ray and cardiac catheterization are used in evaluation. The most frequent acyanotic heart defects are ventricular septal defect, atrial septal defect, patent ductus arteriosus, coarctation of aorta, and pulmonary valve stenosis.
Dr. Nagendra Prasad provides an overview of acyanotic congenital heart diseases. He discusses that they present with signs of congestive heart failure and/or heart murmurs during infancy or early childhood. The most common presentations are feeding difficulties, tachypnea, sweating, subcostal recession, and recurrent respiratory infections. Echocardiography, ECG, chest x-ray and cardiac catheterization are used in evaluation. The most frequent acyanotic heart defects are ventricular septal defect, atrial septal defect, patent ductus arteriosus, coarctation of aorta, and pulmonary valve stenosis.
Tetralogy of Fallot (TOF) is a congenital heart defect characterized by four anatomical abnormalities - ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta. It was first described in detail in 1888. The physiology involves deoxygenated blood from the right ventricle being shunted away from the lungs due to pulmonary stenosis. Severity of cyanosis and murmurs depends on degree of pulmonary stenosis. Management involves treating spells and definitive surgical repair is usually done in early childhood.
This document discusses innocent or physiological murmurs in children. It begins by explaining that murmurs are sounds caused by blood flow through the heart and vessels. In children, most murmurs are innocent and caused by normal blood flow patterns rather than structural abnormalities. The document outlines the pediatric cardiologist's evaluation process for children with murmurs, including physical exam, family history, and tests to determine if the murmur is innocent or indicates an underlying heart condition. It emphasizes that innocent murmurs are common in childhood and not cause for concern as they do not imply structural heart disease.
Congenital heart defects are abnormalities in the heart's structure that are present at birth. They range from simple defects with no symptoms to complex defects that are life-threatening. They affect about 8 in 1,000 newborns. Some defects require immediate medical care, while others need no treatment or can be easily fixed. Common types include atrial septal defects, ventricular septal defects, tetralogy of Fallot, coarctation of the aorta, and patent ductus arteriosus. Treatment options depend on the size and severity of the defect, and may include medications, cardiac catheterization, or open-heart surgery.
History and physical examination of congenital heart diseaseMd Rahman
Congenital heart disease is the most common birth defect, responsible for significant newborn mortality. A thorough physical exam remains important for detecting heart defects and assessing severity despite advances in noninvasive diagnosis. Cyanosis, tachypnea, feeding difficulties, and failure to thrive are common symptoms in infants with congenital heart disease. A detailed family, birth, and medical history is essential to identify risk factors and guide evaluation and management.
This document discusses oral manifestations of various systemic diseases. It covers cardiovascular diseases like congenital heart diseases, rheumatic heart disease, atherosclerosis, and hypertension. It also discusses renal disease, endocrine disorders like disorders of the pituitary and adrenals, and thyroid disorders. Other sections discuss gastrointestinal disorders, collagen vascular diseases, neurological disorders, immunologic diseases, allergies, and respiratory diseases. For each condition, it describes the systemic disease, potential oral manifestations, and considerations for dental management.
This document outlines the steps for performing a pediatric physical examination, including:
1) Taking a family and birth history and assessing growth and development.
2) Evaluating vital signs like blood pressure, heart rate, and respiratory rate and comparing arm and leg blood pressure.
3) Examining the head, neck, chest, heart, lungs, abdomen, and extremities for any abnormalities.
The document outlines the key components of a routine newborn assessment, including establishing a historical database, physical examination, and evaluating for any signs of distress, trauma, or abnormalities. The examination follows a structured process, beginning with observation, then assessing the skin, vital signs, reflexes, measurements, and examining specific body systems like respiratory, cardiovascular, abdominal, genitourinary, and musculoskeletal. The goals are to determine gestational age, evaluate growth and development, and identify any health issues in the newborn.
- Children frequently present to pediatric offices and emergency departments with complaints of chest pain. However, most studies show that serious organic pathology is rare in children with chest pain.
- There are many potential causes of chest pain in children, including cardiac, respiratory, musculoskeletal, gastrointestinal, and psychological conditions. Common causes include chest wall strain, costochondritis, asthma, and stress-related pain.
- It is important for doctors to take chest pain complaints seriously while also considering a broad differential diagnosis, as rare cases can involve underlying heart conditions. Careful history, physical exam, and testing are needed to evaluate children with chest pain.
This document provides information on several types of congenital and rheumatic heart disease, as well as surgical correction of cardiovascular lesions. It discusses congenital heart defects such as atrial and ventricular septal defects, tetralogy of Fallot, coarctation of the aorta, and patent ductus arteriosus. For each condition, it describes the etiology, clinical features, investigations, and management approaches. The document emphasizes that while many congenital heart defects used to be fatal in childhood, surgery can now correct or partially repair many conditions, allowing survival into adulthood.
This document provides an overview of congenital heart disease, including common lesions and their physiology. It discusses the fetal circulation and how defects are more tolerated in utero but often cause issues after birth as pulmonary vascular resistance decreases. Common left-to-right shunt lesions like atrial septal defects, ventricular septal defects, and patent ductus arteriosus are explained. Obstructive lesions such as coarctation of the aorta and pulmonary valve stenosis are also summarized. The document provides details on presentation, diagnosis, and treatment of these various congenital heart conditions.
This document provides information on Ebstein's anomaly, including its anatomy, embryology, clinical presentation, diagnosis, and natural history. Some key points:
- Ebstein's anomaly is a congenital defect involving downward displacement of the tricuspid valve into the right ventricle. This can cause dilation of the right atrium and dysfunction of the right ventricle.
- Clinical presentation varies from neonatal congestive heart failure to later cyanosis, arrhythmias, and right heart failure in adults. Associated defects are common.
- Diagnosis is made through echocardiogram demonstrating displacement of the tricuspid valve leaflets. Other tests like ECG, chest x-ray, and
Management of asymptomatic heart murmurs presents challenges, as most murmurs are benign but parental anxiety is still high. For neonates and young infants, history and examination are important to identify which need referral. Transient murmurs often disappear on their own. For older children, the clinician must determine if the murmur is likely innocent or indicates an underlying condition requiring monitoring or intervention. While many argue all murmurs should receive echocardiograms, it is not always necessary and thorough clinical assessment remains important. Regional pediatric cardiology networks aim to standardize management and ensure children receive the appropriate level of care.
The document discusses cardiovascular disorders in children, including congenital heart diseases like ventricular septal defect (VSD). It provides details on the anatomy and physiology of the cardiovascular system in children, changes after birth, and diagnostic techniques for congenital heart diseases such as echocardiography and catheterization. VSD is described as a hole in the septum between the right and left ventricles allowing left-to-right shunting, which can cause congestive heart failure or pulmonary hypertension.
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Differential diagnosis and approach to a heart murmur in term infants
1. Pediatr Clin N Am 51 (2004) 1023 – 1032
Differential diagnosis and approach to a heart
murmur in term infants
Michele A. Frommelt, MD
Children’s Hospital of Wisconsin, The Medical College of Wisconsin, 9000 West Wisconsin Avenue,
P.O. Box 1997, Milwaukee, WI 53201, USA
The incidence of structural congenital heart disease is estimated to be less than
1% of all live births [1]. In contrast, as many as 90% of children will have an
audible heart murmur at some point in time [2], and Braudo and Rowe reported
a murmur in 60% of healthy newborn babies [3]. It therefore becomes the
clinician’s responsibility to screen infants and children and determine which
patients need further evaluation, because universal screening by echocardiogra-
phy or pediatric cardiology consultation is not economically feasible.
In this article, the author discusses the differential diagnosis and approach to a
heart murmur in the infant born at term but less than 6 months of postnatal age. It
is important to remember that a heart murmur in this age group more frequently
reflects structural heart disease, in contrast to a heart murmur in the toddler or
older child. The author focuses on the most common structural lesions presenting
with a murmur in this age group, reviewing important aspects of the history,
physical examination, and cardiac examination.
History
Although there are many clinical and diagnostic tools that can help us dis-
tinguish the innocent murmur from the pathologic murmur, the value of a com-
plete medical history cannot be overestimated. The historical assessment of the
term infant should include questions about the family, the pregnancy, the peri-
natal course, and early growth and development. Is there a sibling or first-degree
relative with structural heart disease? Are there any known heritable syndromes,
such as Marfan’s syndrome or hypertrophic cardiomyopathy? A maternal history
of diabetes mellitus, especially when poorly controlled during pregnancy, can be
E-mail address: mafrom@mcw.edu
0031-3955/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.pcl.2004.03.003
2. 1024 M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032
associated with significant heart disease in up to 30% of infants [4]. Was the fetus
exposed to alcohol or any maternal medications? Perhaps the most important
questions in the term infant with a heart murmur should focus on the perinatal
course, as well as on the early growth and development. Were there any problems
at the time of birth? Was there any cyanosis or tachypnea? What was the infant’s
birth weight, and has the infant grown appropriately? Although weight gain is
variable in the term infant, most will regain their birth weight by 2 weeks of age,
and double their birth weight by 6 months of age [5]. An accurate feeding history
is of the utmost importance, because feeding difficulties are common manifes-
tations of congestive heart failure in the infant. When taking the feeding history,
one must not only inquire about volume per feeding, but also inquire about length
of time per feeding, and associated symptoms such as tachypnea or diaphoresis.
Although infants with a large ventricular septal defect may take four ounces per
feeding, it typically takes them much longer to complete the feeding, with
frequent breaks, presumably from the combined effort of sucking and maintain-
ing a rapid respiratory rate. Early developmental milestones can be delayed,
especially gross motor milestones.
Table 1
Malformation syndromes associated with congenital heart disease
Syndrome Cardiac defect
Alagille (arteriohepatic dysplasia) Peripheral pulmonary stenosis
Coloboma, Heart defects, Atresia Ventricular, atrioventricular, and atrial septal defects
of the choanae, Retardation of
growth and development, Genital
and urinary abnormalities, Ear
abnormalities and/or hearing
loss (CHARGE)
De Lange’s Tetralogy of Fallot, ventricular septal defect
DiGeorge Aortic arch anomalies, tetralogy of Fallot
Down Atrioventricular septal defects, ventricular septal defect
Fetal alcohol Ventricular septal defect, atrial septal defect, tetralogy
of Fallot
Goldenhar’s Tetralogy of Fallot
Holt-Oram Atrial or ventricular septal defect
Laurence-Moon-Biedl Tetralogy of Fallot, ventricular septal defect
Multiple lentigenes (leopard) Pulmonary stenosis
Noonan’s Pulmonic stenosis, atrial septal defect
Rubella Patent ductus arteriosus, peripheral pulmonary stenosis
Rubinstein-Taybi Patent ductus arteriosus
Scimitar Hypoplasia of the right lung, anomalous pulmonary
drainage
Smith-Lemli-Opitz Ventricular septal defect, patent ductus arteriosus
Thrombocytopenia-absent radius(TAR) Atrial septal defect, tetralogy of Fallot
Turner’s Coarctation of the aorta, bicuspid aortic valve
Velocardiofacial Ventricular septal defect, right aortic arch
Williams Supravalvular aortic stenosis, peripheral pulmonary
stenosis
3. M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032 1025
General examination
Any physical examination in the term infant should begin with a general
assessment of overall appearance. Does the infant appear robust, playful and
comfortable, or is the infant irritable, diaphoretic, and breathless? Are there any
dysmorphic features or extracardiac anomalies? Although structural congenital
heart disease can be an isolated abnormality, there are a great number of
malformation syndromes involving the cardiovascular system (Table 1). Growth
parameters should be plotted on appropriate growth charts, and vital signs should
be recorded. Heart rate, respiratory rate, and blood pressure should be measured.
Although it may require a team effort to measure an accurate blood pressure in
the infant, this is a critical but often neglected part of the infant examination. Are
there any signs of respiratory distress, such as tachypnea, retractions, grunting, or
nasal flaring? Is the infant pink, or is there subtle cyanosis of the mucous
membranes? Acrocyanosis (bluish discoloration of the skin related to vasospasm
of the subcutaneous blood vessels) should be differentiated from true central
cyanosis, because acrocyanosis is a normal phenomenon in the young infant.
Acrocyanosis is commonly noted on the hands and feet, and occurs on exposure
to cold, generally improving with activity. If there is any question, pulse oximetry
is indicated. Hepatomegaly is common in infants with congestive heart failure, so
a relaxed abdominal examination is very important. The typical signs of venous
congestion that are seen in the adult are rare in the infant. Jugular venous
distention is difficult to assess, and peripheral edema is usually secondary to renal
disease with hypoproteinemia, not cardiac disease.
Cardiac examination
The cardiac examination should be performed in a systematic manner, so that
one does not become unduly focused on a single finding; however, one needs to
be flexible enough to alter the approach, especially in the term infant, who is not
always quiet or sleeping. One general approach is to start with inspection and
palpation, and to do this appropriately, one needs to lay the hands directly on the
chest. Is there a left-sided precordial bulge, suggesting cardiac enlargement? Is
there a substernal heave, indicating right ventricular hypertension? Is there a
palpable precordial thrill? Any of these additional findings in the term infant with
a heart murmur suggest that the murmur is indeed pathologic. If the infant is
quiet, one may then go on to auscultation, again remembering to approach this in
a systematic manner. The first heart sound, reflective of mitral and tricuspid valve
closure, is typically single and is best heard at the left lower sternal border. The
second heart sound, reflective of aortic and pulmonary valve closure, is split,
varies with respiration, and is best heard at the left upper sternal border.
Abnormalities of the second heart sound are often seen in congenital heart
disease, making it perhaps the most important element of auscultation in the
pediatric patient. Third and fourth heart sounds can be normal in the child, are
4. 1026 M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032
typically low in frequency, and are best heard at the cardiac apex. Systolic
ejection clicks are typically high in frequency, occur early in systole, and often
reflect semilunar valvar stenosis. Murmurs should be described by their intensity
and timing, as well as their location and radiation. Any variability that occurs
with a change in position or with a maneuver should be described. The Grade I
murmur is barely audible and often only heard in a quiet environment with a
cooperative child. The Grade II murmur is soft but easily audible, whereas the
Grade III murmur is loud and often recognized immediately when placing the
stethoscope on the chest. The Grades IV, V, and VI murmurs are associated with a
palpable precordial thrill, and are always pathologic. The ability to discern the
Grade V murmur (audible with the edge of the stethoscope on the chest wall) or
Grade VI murmur (audible with the stethoscope off the chest wall) adds little to
the diagnosis. After grading the murmur, one must define the timing of the
murmur, or when it occurs within the cardiac cycle. Is it systolic, diastolic, or
continuous (throughout the cardiac cycle)? The two major types of systolic
murmurs are the systolic ejection murmur and the systolic regurgitant murmur.
The systolic ejection murmur is harsh, starts beyond the first heart sound, and is
diamond-shaped. The systolic regurgitant murmur is blowing, starts with and
obscures the first heart sound, and plateaus throughout its course. The innocent
murmurs are soft (Grade I or II) and ejection in quality; the pathologic systolic
murmur occurs early in systole and can be quite loud. Although diastolic mur-
murs are much less common in the child, the auscultation of a diastolic murmur
indicates that structural heart disease is present. Continuous precordial murmurs
in infants are also generally pathologic, with the exception of the cervical venous
hum. The venous hum, an innocent murmur related to turbulent flow at the
junction between the jugular vein and the superior vena cava, should resolve in
the supine position or with gentle compression of the jugular vein. After cardiac
auscultation is performed, one should assess the peripheral pulses for rate,
rhythm, and character. Are the pulses weak or bounding? Are the pulses sym-
metric? Feeling the femoral pulses is a critical part of the cardiac examination,
because weak or absent femoral pulses are the hallmarks of aortic coarctation.
Last, a simple, noninvasive indicator of cardiac output is the measured capillary
refill time. This is obtained by blanching the nail bed or digit, and observing the
time to reperfusion, typically less than 3 seconds.
Specific lesions
Peripheral pulmonary stenosis
Several studies in the literature have suggested that innocent heart murmurs in
healthy term infants are mostly related to pulmonary branch stenosis, which is
reduced in two thirds of cases by 6 weeks of age and in most others by 6 months
[6]. The etiology of the murmur is secondary to both relative hypoplasia of the
pulmonary artery branches and an associated angulation at their origin [7]. The
5. M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032 1027
murmur is soft (Grade I or II), ejection in quality, and best heard anteriorly
at the left upper sternal border; however, the murmur is clearly recognized
by its characteristic transmission to the axillae and back bilaterally, and by its
disappearance over time. There are no associated signs or symptoms of heart
disease, and the rest of the cardiac examination is normal. The pulmonary flow
murmur of an atrial septal defect may mimic this murmur, but is generally heard
in later infancy or childhood. Pulmonary valve stenosis is of louder intensity
and is associated with an early systolic ejection click; severe stenosis can re-
sult in a precordial thrill. Pathologic peripheral pulmonary stenosis is typically
more severe, generating a louder murmur, and does not regress over time.
Associated noncardiac anomalies and dysmorphic features are common with
pathologic branch stenosis. Coarctation of the aorta can result in a murmur at the
left upper sternal border and left back; however, a careful assessment of lower
extremity pulses should easily differentiate aortic coarctation from pulmonary
branch stenosis.
If peripheral pulmonary stenosis is suspected in the term infant with a heart
murmur, close follow-up by the clinician is indicated. If the murmur intensifies or
persists after 6 months of age, cardiology referral is indicated.
Ventricular septal defect
Excluding the bicuspid aortic valve, which may be difficult to recognize in
neonates, isolated ventricular septal defects are the most common congenital
heart defect identified through the first 3 decades of life, with an incidence from
1 to 7 per 1000 live births [8]. Certainly, in the experience of the author and
others [9], the term infant with a pathologic heart murmur is more likely to have
an isolated ventricular septal defect than any other form of congenital heart
disease. It is important to remember that these infants can present in different
ways, and that the presentation is determined by the size of the defect and the
status of the pulmonary vascular resistance.
Most commonly the murmur is detected at 2 to 6 weeks of age, when the
infant returns for the initial checkup after hospital discharge; however, in the
presence of a small defect associated with a normal fall in pulmonary vascular
resistance, the murmur can be heard during the first few days of life. The infant
with a small ventricular septal defect otherwise appears healthy, with normal
growth and no cardiac symptoms. The precordial activity is normal, and there
typically is not a palpable systolic thrill. The murmur of a small ventricular septal
defect can be quite loud, reflecting the normal drop in pulmonary vascular
resistance and resultant high-velocity, turbulent jet of flow between the higher-
pressured left ventricle and the lower-pressured right ventricle. Of note, if a small
muscular defect is present, the murmur is softer and confined to early systole,
because these defects are obliterated in mid systole with ventricular contraction.
The infant with a moderate-sized ventricular septal defect is often of small size,
with decreased weight gain, and the parents may note dyspnea and diaphoresis,
especially with feedings. Although the pulmonary vascular resistance has typi-
6. 1028 M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032
cally fallen, the moderate defect allows a more significant volume left-to-right
shunt, leading to cardiomegaly and a hyperdynamic precordium. The murmur
is always loud, is frequently associated with a systolic thrill, and is harsh and
holosystolic, obscuring the first and second heart sounds. Because of the increased
pulmonary blood flow, which is often twice the systemic flow, a prominent third
heart sound or diastolic flow murmur can be heard at the cardiac apex. This
reflects the increased flow across the mitral valve, causing a relative mitral
stenosis murmur in mid-diastole. The infant with a large ventricular septal defect
can be more of a diagnostic dilemma, but should be recognized because of sig-
nificant clinical symptoms and failure to thrive. Feeding problems and irritability
are common, and infants may be misdiagnosed with colic or gastroesophageal
reflux. The large defect allows a significant volume left-to-right shunt and left
heart volume overload, leading to an increased left-ventricular precordial im-
pulse. Because the pulmonary vascular resistance remains moderately elevated
with resultant right ventricular and pulmonary artery hypertension, there is a
marked right ventricular heave, with a loud and single second heart sound. The
murmur is soft (Grade II), short and early systolic, again reflecting the significant
elevation in right ventricular and pulmonary artery pressures. A prominent third
heart sound and diastolic rumble are common. These infants will also have
hepatomegaly, and systemic perfusion can be compromised.
If a ventricular septal defect is suspected in the term infant with a heart
murmur, cardiology referral is indicated to confirm the diagnosis, but the
urgency of referral depends on the clinical symptoms. Patients with small
defects have an excellent prognosis, with spontaneous closure occurring in
75% to 80% of patients during the first 2 years of life [10]. There are no data
to suggest a decreased life expectancy; thus surgical closure is not indicated
[11]. Although these patients are at risk for endocarditis if the defect remains
patent, endocarditis is extremely rare in the infant. Patients with moderate to
large defects will likely benefit from medical or surgical therapy, with improved
growth potential and less risk of pulmonary vascular disease, so urgent referral
is warranted in these subgroups.
Tetralogy of Fallot
Tetralogy of Fallot refers to a spectrum of anatomic abnormalities that have a
large ventricular septal defect and right-ventricular outflow tract obstruction. This
was beautifully described by Fallot in 1888 and termed ‘‘maladie bleue.’’ It is the
most common form of cyanotic congenital heart disease, and accounts for about
6% of all infants born with congenital heart disease. The clinical presentation
depends on the severity of right-ventricular outflow tract obstruction; however,
most infants present with a murmur in the early neonatal period secondary to
turbulence through the right ventricular outflow tract. If the degree of right
ventricular outflow tract obstruction is severe, the infant can present with severe
cyanosis as the patent ductus arteriosus closes. At the time of presentation, the
infant often appears healthy, although there is a higher incidence of extracardiac
7. M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032 1029
anomalies and malformation syndromes in this group of patients. Subtle cyanosis
may be noted. The right ventricular impulse is increased, because the right
ventricle ejects at systemic pressure, and there may be a systolic thrill in infants
with a moderate degree of obstruction. The second heart sound is typically single,
because one does not hear the pulmonary component in the setting of a dilated
aortic root and a hypoplastic, less-mobile pulmonary valve. It is important to
remember that the systolic murmur in tetralogy of Fallot originates at the zone of
stenosis, and not across the ventricular septal defect. The murmur can be quite
loud, is ejection in quality, and diminishes in intensity and length when the degree
of obstruction increases. If a prominent diastolic murmur is also heard, one should
suspect pulmonary valve dysplasia, and in this setting, markedly-dilated branch
pulmonary arteries may cause airway obstruction and respiratory symptoms.
If tetralogy of Fallot is suspected in the term infant with a heart murmur, pulse
oximetry should be performed. Many infants with tetralogy who present with a
prominent murmur have only mild desaturation/cyanosis at rest, which is not
easily recognized with the eye alone. A chest radiograph may demonstrate a boot-
shaped heart, reflective of the associated right-ventricular hypertrophy. Identifi-
cation of a right aortic arch should raise suspicion of this diagnosis, because it is
found in approximately one third of patients with tetralogy of Fallot. Prompt
cardiology referral is indicated in all patients.
Pulmonary stenosis
Isolated pulmonary valve stenosis is fairly common, accounting for about 10%
of congenital heart disease. A useful feature is a prominent murmur detected in
the newborn nursery, because the anatomic and physiologic conditions for the
murmur are present at birth. The intensity of the murmur depends on the severity
of obstruction; soft murmurs of mild obstruction may be overlooked for many
years. The infant otherwise appears well with, at times, a cherubic facies. The
right ventricular impulse is prominent, and there may be a systolic thrill at the left
upper sternal border if the obstruction is severe. An ejection sound is character-
istic of pulmonary valve stenosis, and is easily recognized by its high-pitched
clicking quality, varying with respiration. The pulmonic component of the second
heart sound is delayed and soft, because right ventricular ejection is prolonged.
The murmur is often loud, ejection in quality, and is best heard at the left upper
sternal border.
If pulmonary valve stenosis is suspected in the term infant with a heart
murmur, elective cardiology referral is indicated. These infants typically do well
for many years without intervention; however, balloon dilatation is indicated in
those with a moderate degree of obstruction.
Atrial septal defect
Secundum atrial defects are most common in females and are sometimes
familial, occurring through a number of generations [12]. Because the clinical
8. 1030 M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032
findings are subtle and symptoms are rare, isolated atrial septal defects account
for fewer than 10% of cases of congenital heart disease in infants, but for more
than 30% of cases of congenital heart disease in adults. Although it is less com-
monly diagnosed in infancy, it is important to recognize the features, because
they do become apparent during the first year of life. Also, when unrecognized in
childhood, the patient is at risk for pulmonary vascular disease, arrhythmias, and
a decreased life span.
Isolated atrial septal defects are rarely diagnosed in the neonate, because left-
atrial to right-atrial shunting is established only gradually as the right ventricle
thins after the fall of the high fetal pulmonary vascular resistance. Clinical
symptoms are typically absent; however, on occasion the infant with a large
defect and a relatively small left ventricle presents with congestive heart failure.
Young children with atrial septal defects often have a thin habitus. Precordial
palpation is abnormal, with a prominent hyperdynamic right-ventricular impulse.
At times, one may actually palpate the dilated main pulmonary artery trunk in
the second left intercostal space. The auscultatory hallmark of the atrial septal
defect is wide, fixed splitting of the second heart sound. Wide splitting reflects
delayed closure of the pulmonary valve, and most practitioners feel that this is
related to increased pulmonary vascular capacitance [13]. The murmur accom-
panying the atrial defect is usually prominent (Grade II or III), systolic ejection in
quality, and heard best at the left upper sternal border. The murmur reflects
increased right-ventricular stroke volume across the pulmonary valve. This in-
creased stroke volume also crosses the tricuspid valve in diastole, creating a mid-
diastolic flow rumble.
When a systolic ejection murmur is heard at the left upper sternal border in the
term infant, the differential diagnosis includes atrial septal defect, valvar pul-
monary stenosis, branch pulmonary artery stenosis, and tetralogy of Fallot.
Careful auscultation of the second heart sound should differentiate these lesions.
Pulse oximetry should be normal in all of the lesions except tetralogy of Fallot.
Although cardiology referral is certainly indicated when an atrial defect is sus-
pected, most infants are asymptomatic and there are many reports of spontaneous
closure over time [14]. Surgical or catheter closure of these defects is generally
not performed until 3 or 4 years of age, because of the lack of symptoms and the
possibility of spontaneous closure.
Aortic stenosis
The bicuspid aortic valve is the most prevalent congenital heart abnormality,
estimated to be present in 1% to 2% of the population [15]. It is much more
common in males, with a sex ratio of approximately 4:1. Many bicuspid valves
will function normally for many years until calcification occurs in adulthood;
however, the bicuspid aortic valve can be stenotic at birth. Just as in the infant
with valvar pulmonary stenosis, a helpful feature in the history is a murmur
noted in the newborn nursery, because the anatomic and physiologic conditions
are present to generate the heart murmur. Most infants with valvar aortic stenosis
9. M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032 1031
are otherwise healthy, with appropriate growth and development. One notable
exception is the neonate with such severe aortic stenosis at birth that left-
ventricular output is compromised. These infants are characterized as having
‘‘critical’’ aortic stenosis, and usually present with marked left-ventricular
dysfunction, congestive heart failure, and low cardiac output. It is important
to remember that these neonates may not have a prominent murmur, because
there is limited antegrade flow across the aortic valve. The left ventricular im-
pulse can be normal in mild obstruction or increased in more moderate obstruc-
tion. A systolic thrill is common in aortic stenosis, and is readily detected in the
suprasternal notch and over both carotid arteries. An ejection sound is also
characteristic of aortic stenosis and is best heard at the cardiac apex. The mur-
mur is maximal in the second right interspace, with radiation to the right and
into the neck. The intensity of the murmur is variable, with an ejection quality.
A general rule is that the louder, longer, late-peaking murmur is indicative
of more significant obstruction. Peripheral pulses and perfusion are generally
good, except in the neonate with critical obstruction, in whom pulses are dif-
fusely diminished.
If aortic stenosis is suspected in the term infant with a heart murmur,
cardiology referral is indicated, with more urgent referral in the neonate or
young infant.
Coarctation of the aorta
Coarctation of the aorta is an obstruction in the descending aorta near
the insertion of the ductus arteriosus. It accounts for about 5% to 10% of all
congenital heart defects, and tends to be more common in males. The neonate
with severe obstruction will present early in life with low cardiac output, and is
not the focus of this discussion. The majority of patients with aortic coarctation
present in later childhood and are asymptomatic, and approximately 50% are
referred to the pediatric cardiologist with a heart murmur [16]. It is imperative
that we improve our diagnostic skills in this group of patients, because long-
term sequelae and survival are significantly better with early diagnosis and
repair [17].
It is critically important for clinicians to examine femoral pulses in all infants
and children, because the hallmark clinical feature of aortic coarctation at any age
is absent or weak femoral pulses. The diagnosis can be confirmed by the clinician
when a higher measured blood pressure is observed in the arm compared with the
leg. A systolic ejection click may be heard if there is an associated bicuspid aortic
valve. The murmur is generally soft (Grade II), ejection in quality, and audible at
the left upper sternal border as well as over the left back. The murmur can
resemble the murmur of peripheral pulmonary stenosis, but should be readily
differentiated by the discrepancy in femoral pulses.
If the term infant with a heart murmur is suspected to have aortic coarctation,
urgent cardiology referral is indicated so that the severity of the obstruction can
be assessed.
10. 1032 M.A. Frommelt / Pediatr Clin N Am 51 (2004) 1023–1032
Summary
In conclusion, heart murmurs in the term infant are frequently reflective of
structural congenital heart disease. A detailed history, physical examination, and
cardiac examination should help the clinician formulate a differential diagnosis.
Pediatric cardiology referral is indicated when the murmur is felt to be
pathologic, with more urgent referral in the symptomatic infant.
References
[1] Hoffman JIE. Incidence of congenial heart disease: I. Postnatal incidence. Pediatr Cardiol 1995;
16:103 – 13.
[2] Harris JP. Evaluation of heart murmurs. Pediatr Rev 1995;12:490 – 3.
[3] Braudo M, Rowe RD. Auscultation of the heart—early neonatal period. Am J Dis Child 1961;
101:575 – 86.
[4] Cooper JJ, Enderlein MA, Tarnoff H, Roge CL. Asymmetric septal hypertrophy in infants of
diabetic mothers: Fetal echocardiography and the impact of maternal diabetic control. Am J Dis
Child 1992;146:226 – 9.
[5] Kaplan SL. Growth: normal and abnormal. In: Rudolph AM, Hoffman JIE, editors. Pediatrics.
Norwalk (CT): Appleton-Century-Crofts; 1977. p. 83 – 104.
[6] Arlettaz R, Archer N, Wilkinson AR. Natural history of innocent heart murmurs in newborn
babies: controlled echocardiographic study. Arch Dis Child Fetal Neonatal Ed 1998;78:166 – 70.
[7] Danilowicz DA, Rudolph AM, Hoffman JIE, Heymann M. Physiologic pressure differences
between main and branch pulmonary arteries in infants. Circulation 1972;45:410 – 9.
[8] Graham TP, Bender HW, Spach MS. Ventricular septal defect. In: Adams FH, Emmanouilides
GC, Riemenschneider TA, editors. Moss’ heart disease in infants, children, and adolescents.
Baltimore (MD): Williams & Wilkins; 1989. p. 189 – 209.
[9] Ainsworth SB, Wyllie JP, Wren C. Prevalence and clinical significance of cardiac murmurs in
neonates. Arch Dis Child Fetal Neonatal Ed 1999;80:43 – 5.
[10] Alpert BS, Cook DH, Varghese PJ, Rowe RD. Spontaneous closure of small ventricular septal
defects: ten-year follow-up. Pediatrics 1979;63:204 – 6.
[11] Weidman WH, DuShane JW, Ellison RC. Clinical course in adults with ventricular septal defect.
Circulation 1977;56:178.
[12] Howitt G. Arial septal defet in three generations. Br Heart J 1961;23:494.
[13] Atrial septal defect. In: Perloff JK, editor. The clinical recognition of congenital heart disease.
Philadelphia: WB Saunders; 1972. p. 272 – 349.
[14] Senocak F, Karademir S, Cabuk F, Onat N, Koc S, Duman A. Spontaneous closure of interatrial
septal opening in infants: an echocardiographic study. Int J Cardiol 1996;53:221 – 6.
[15] Roberts WC. The congenitally bicuspid aortic valve. A study of 85 autopsy cases. Am J Cardiol
1970;26:72.
[16] Ing FF, Starc TJ, Griffiths SP, Gersony WM. Early diagnosis of coarctation of the aorta in
children: a continuing dilemma. Pediatrics 1996;98:378 – 82.
[17] Maron BJ, Humphries JO, Rowe RD, Mellitts ED. Prognosis of surgically corrected coarctation
of the aorta: a 20-year post-operative appraisal. Circulation 1973;47:119 – 26.