TCH APP Conference April 2019multitonal) 34 CongenitalHeartDefects Atrial&Septal&Defect& Patent&Ductus&Arteriosus& Ventricular&Septal&Defect& PulmonaryStenosis Aortic&Stenosis 35 CHD:AtrialSeptalDefect

Murmurs and the Cardiac Physical Exam

Carolyn A. Altman Texas Children’s Hospital Advanced Practice Provider Conference Houston, TX April 6 , 2018

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The Cardiac Physical Exam

Before applying a stethoscope…..

Some pearls on • General appearance • Physical exam beyond the heart

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Jugular Venous Distention Pallor

Cyanosis

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Work of Breathing

Normal infant breathing

Quiet Tachypnea

Increased Rate, Work of Breathing

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Beyond the Chest

Clubbing

Observed in children older than 6 mos with chronic cyanosis

Loss of the normal angle of the nail plate with the axis of the finger

Abnormal sponginess of the base of the nail bed

Increasing convexity of the nail

Etiology: ? sludging

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Chest

❖ Chest wall development and symmetry

❖ Long standing cardiomegaly can lead to hemihypertrophy and flared rib edge: Harrison’s groove or sulcus

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Ready to Examine the Heart

Palpation

Auscultation

General overview

Defects

Innocent versus pathologic

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Cardiac Palpation

❖ Consistent approach: palm of your hand, hypothenar eminence, or finger tips

❖ Precordium, suprasternal notch

❖ PMI?

❖ RV impulse?

❖ Thrills?

❖ Heart Sounds?

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Cardiac Auscultation

Where to listen:

★ 4 main positions

★ Inching

★ Ancillary sites: don’t forget the head in infants

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Focus separately on

v Heart sounds:

• S2 normal splitting and intensity?

• Abnormal sounds? Clicks, gallops

v Murmurs

v Rubs

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Etiology of heart sounds: Aortic and pulmonic valves actually close silently

Heart sounds reflect vibrations of the cardiac structures after valve closure

Sudden deceleration of retrograde flow of the column of blood in the aorta and pulmonary artery when the elastic limits of the tensed valve leaflets are met

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S2

❖ Physiologic splitting of S2: Increased systemic venous return and increased pulmonary capacitance during inspiration causes delayed closure of the pulmonary valve

❖ S2 cannot be considered “normal” unless physiologic splitting is heard

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S2: normal splitting Single S2: Pulmonar Hypertension

Wide, fixed splitting: ASD Paradoxical Splitting of S2: LBBB, severe LVOTO

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S2 HInts

❖ If splitting persists while patient supine, try sitting position-‐ less volume in heart may normalize splitting

❖ Listen for splitting at mid to ULSB in kids

❖ Infants: Mid to LLSB ❖ Splitting of S2 if the HR is over 160

hard to hear: gently blowing a breath in the baby’s face will slow HR

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Cardiac Auscultation: S1

❖ Physiologic splitting of S1:

❖ Can be heard in children with slower heart rates.

❖ Varies with respiration as does S2

❖ Soft S1: low cardiac output, tachycardia

❖ Loud S1: hyperdynamic (fever, exercise), mitral stenosis

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Gallops: S3 or S4

❖ Short, low pitched diastolic sounds

❖ Abnormal ventricular function

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Auscultation: S3 Gallop

❖ Mid way thru diastole

❖ Muscle tensing at end of rapid, early filling which occurs with ventricular relaxation

❖ Later than split S2

❖ Earlier than S4

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Auscultation: S4 Gallop

❖ If impaired ventricular relaxation, less filling of the ventricles during during early diastole and more during atrial contraction

❖ Hypertrophic cardimyopathy, eg

❖ S4 is thus a sound generated late in diastole

❖ Very close to S1, can mistake for split S1 or S1-‐ ejection click

S1-Ej click S4

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S3 and S4 Gallops

❖ Heard best with bell since low pitched

❖ Can extinguish the sound by pressing too hard (turning bell into diaphragm)

❖ Usually heard over mitral area, if LV dysfunction

❖ Listen in left lateral decubitus position too

❖ If RV dysfunction-‐may hear best at LLSB

S4

S3

S1-Ej click

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Other Extra Heart Sounds

❖ Ejection Click: opening of the aortic or pulmonary valve

❖ Mid-‐systolic click: MVP

❖ Opening snap of MS

❖ Listen for difference in timing, cadence

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How to Characterize Murmurs

❖ Timing

❖ Site of maximum intensity

❖ Intensity

❖ Radiation

❖ Pitch:

❖ Associated findings: clicks, rumbles, precordial activity

❖ Different from previous in your patient

❖ Innocent or pathologic

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Timing of Murmurs

Systolic ? Diastolic? or Continuous ?

❖ Systolic occurs as the heart contracts

❖ Diastolic as the heart relaxes

❖ Continuous murmurs continue from systole into diastole

❖ Find S2 and listen to whether the murmur comes before it, after it, or through it

❖ Inching the stethoscope can help with timing

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Murmurs: Timing

Systolic murmurs:

❖ Regurgitant murmurs: Begin with S1

❖ Ejection murmurs: Begins shortly after S1

❖ Mid-‐systolic: MVP

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Regurgitant Systolic Murmurs

❖MR, TR, VSD

❖Begin with S1: “coincident with S1”

❖Often holosystolic

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Systolic Ejection Murmurs

❖AS/PS, Still’s, pulmonary flow

❖Begin after valve opens, so hear S1 then murmur

❖ Should be able to hear S2 distinctly

❖ Early systolic ejection click if semilunar valve stenosis

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Mid Systolic Murmurs

❖Mitral valve prolapse

❖Click ushers in murmur

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Diastolic murmurs

Aortic or pulmonary regurgitation:

❖High pitched

❖Decrescendo

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Diastolic murmurs

Diastolic rumbles:

❖ Increased volume across MV or TV

❖ Low pitched filling noise

❖ Absence of silence

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Continuous Murmurs

❖ Start during systole, continue past S2

❖ Louder in systole: PDA, AVM, shunts

❖ Louder in diastole: venous hums, coronary fistula

PDA Coronary fistula AVM

Venous Hum

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Murmurs by location of greatest intensity:

Helpful in figuring out what is generating the murmur

❖ URSB: Aortic stenosis ❖ ULSB: Pulmonary

stenosis, pulmonary flow, ASD

❖ LLSB: VSD, Still’s, TR ❖ Apical: Mitral

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Characterize Murmurs:

Grading system allows accurate communication between caretakers

❖ Grade I: is there something there? ❖ Grade II: Ok, I can hear it ❖ Grade III: Boy, that’s loud ❖ Grade IV: Associated with a thrill, knock your socks

off loud ❖ Grade V: Audible with scope off chest ❖ Grade VI: Audible without stethoscope

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Characterize Murmurs:

Important to follow trends: ❖ Is an aorto-‐pulmonary shunt murmur getting softer?

A shunt may be getting obstructed, outgrown, or PVR elevated

❖ Is the outflow tract obstruction getting worse in a patient with new chest pain?

❖ Is the patient with TOF spelling or just colicky: the outflow murmur will get softer during a spell as less flow traverses the RVOT

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Characterize Murmurs by Pitch:

❖ High

❖ Low

❖ Harsh (multitonal)

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Congenital Heart Defects

❖ Atrial Septal Defect ❖ Patent Ductus Arteriosus ❖ Ventricular Septal Defect ❖ Pulmonary Stenosis ❖ Aortic Stenosis

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CHD: Atrial Septal Defect

❖ Anatomy: described by location in the septum Secundum Primum Coronary Sinus Sinus Venosus

❖ Physiology and physical signs the same, regardless of location of ASD

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Physiology: Amount of shunting depends on

v Size of defect v Differences in compliance between RV

and LV-‐ flow is usually left to right

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Palpation: right ventricular impulse from increased RV volume

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❖ Widely split S2: v Persistent separation

of A2P2 components of S2 throughout respiratory cycle

v Increased pulmonary capacitance or

v Reciprocal changes in flow into the right atrium from the defect or systemic veins

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❖ Pulmonary flow murmur: v Large volume of blood crossing the

pulmonary valve v ULSB to back v Ejection v Medium pitched

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Diastolic Rumble: Consistent with at least 2:1 Qp:Qs Low pitched Listen with bell at LLSB

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CHD: Patent Ductus Arteriosus

Physiology: v In the setting of low

pulmonary vascular resistance, flow is continuous, left to right

v If large PDA, PA pressures may be high: flow can be

•Left to right •Bidirectional •All right to left

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CHD: Patent Ductus Arteriosus

Palpation ❖ RV impulse if pulmonary hypertension ❖ Hyperactive LV impulse if large volume

of flow PDA

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CHD: PDA Murmur

v Continuous if low pulmonary vascular resistance

v Machinery like v Accentuated at end systole v Left infra-‐clavicular area, back, and left

supraclavicular areas

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CHD: Ventricular Septal Defect

Anatomy described by location Perimembranous Inlet Muscular Doubly committed-‐

juxtarterial

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CHD: VSD

Physiology: amount of shunting depends on

❖ Size of defect

❖ Pulmonary resistance: more shunting with decreasing resistance

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CHD: VSD

Palpation: ❖ Quiet precordium? ❖ RV impulse may be present with volume or pressure loading

❖ +/-‐ thrill: cannot determine size by presence of thrill

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CHD: VSD

S2 in VSDs can be ❖ Normally split (typical) ❖ Widely split if very generous amount of flow crossing to fill RV ❖ Single: if pulmonary hypertension with elevated resistance

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CHD: VSD Auscultation

Murmur ❖ Usually along LSB ❖ Very small defects do not radiate ❖ Subpulmonary VSDs follow the RV

outflow to the pulmonary arteries ❖ “Blowing” quality ❖ Start with S1

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CHD: VSD murmurs

Holosystolic murmur: ❖ Starts with S1

(obscured) ❖ Ends with P2, S2 split

normally ❖ Plateau shape ❖ The smaller the defect,

the more high pitched

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CHD: VSD murmur

Short systolic murmur consistent with very small defect v Starts with S1 v Ends before S2, as defect closed by ventricular

contraction v Usually very localized, may only hear in certain

positions

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CHD: VSD

Mitral Rumble

vIndicates at

least 2:1 Qp:Qs

vLow pitched

vUse bell at apex

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CHD: VSD

Diastolic rumble

Can be quite subtle

Listen for absence of diastolic silence

Compare right and lef chest

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CHD: VSD

Very Large VSDs

vAllow high pressure and high flow

v If lef unrepaired: elevated PVR develops,

eventually Eisenmenger syndrome

Palpahon

v RV impulse

v Palpable S2

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CHD: VSD

Large VSDs:

Systolic Murmur

vCan be holosystolic, if any pressure restrichon

v If no pressure restrichon, may be no murmur, or a pulmonary ouilow murmur

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CHD: VSD

Eisenmenger’s

v S2 loud and single

v Pulmonary valve click: dilated pulmonary root

v Graham-‐Steele murmur: pulmonary insufficiency

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CHD: Tetralogy of Fallot

Physiology:

v Balance between VSD flow and pulmonary valve and sub valve stenosis

v “Pink” tets have little pulmonary stenosis

v Other extreme: pulmonary atresia with VSD

v PS typically progresses over time

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CHD: TOF

Palpahon:

v RV impulse

v Possible thrill

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CHD: TOF

Systolic Murmur: reflects PS, not VSD

v MLSB to ULSB to back

v Starts with S1, given subvalvar component

v As subps worsens, murmur decreases in intensity: pop-‐off through VSD to systemic circulahon

v Listen for murmur to decrease in hypercyanohc spell

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CHD: TOF

❖ Systolic Murmur: reflects PS, not VSD

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CHD: TOF post repair

To and fro murmur ❖ PS/PI ❖ The murmur does

not carry through S2-‐not continuous, not the diastolic component

❖ The diastolic murmur is of a different pitch

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CHD: Pulmonary Valve Stenosis

❖ Anatomy: thickened, possibly dysplashc valve with limited systolic excursion

❖ Physiology: usually slowly progressive obstruchon

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Palpahon:

v RV impulse: more than mild obstruchon

v Thrill indicates more severe obstruchon

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Systolic Ejechon Click:

v Either at ULSB, or upstream from valve at LLSB

v Increases in intensity with expirahon

v Moves closer to S1 with increasing PS

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Systolic Murmur:

v Louder, longer, and later peaking with increasing stenosis

v ULSB radiahng to back, axilla

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CHD: Aortic Valve Stenosis

Anatomy:

Thickened valve with decreased excursion

Ofen bicommissural

Physiology:

Obstruchon can be rapidly progressive, parhcularly in infants

Exercise increases the relahve stenosis

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Palpahon:

v Increased LV impulse with significant obstruchon

v Thrills frequently presents

vDo NOT reflect severity

vCan be along LVOT, ULSB, carohds, suprasternal notch

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Ejechon click: vOpening of non-‐compliant valve

v Moves earlier in systole with increasing severity of obstruchon, may become inaudible

v Heard at apex (upstream) or URSB (downstream)

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Murmur:

v With increasing stenosis and normal cardiac output, murmur becomes louder, longer, later peaking

vMay not have significant murmur if poor funchon (neonatal AS)

v Heard at apex (upstream) or URSB (downstream)

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Innocent Murmurs:

❖ Learn to recognize the three most common innocent murmurs of childhood: ❖ Venous hums, ❖ Still’s murmurs ❖ Physiologic pulmonary branch stenosis

in infancy

❖ Anything else is not likely to be normal!

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Innocent Murmurs: Still’s

Shll’s: most common innocent murmur

❖ I-‐III/VI SEM

❖ Sofer with standing or sinng

❖ Vibratory, twanging

❖ Low pitched, best heard with bell

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Still’s murmur versus subaortic stenosis

Subaortic stenosis can mimic Still’s: both can be musical

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Still’s murmur versus Subaortic Stenosis

❖ Use positional changes to help distinguish subAS from Still’s

❖ Dynamic obstruction in HCM accentuated with decrease in filling: murmur gets louder with stand

❖ Discrete sub AS will not usually get louder, but will also not diminish with stand

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Innocent Murmur: Venous Hum

Venous Hum: innocent continuous murmur

❖ Turbulent flow merging from internal jugular and subclavian veins into SVC

❖ Louder in diastole

❖ Disappear when patient lies supine or turns head

❖ Audible along infraclavicular area, and low anterior neck (not the head)

❖ I-‐III/VI

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Innocent Murmur: Venous Hum

Continuous murmur: whining, roaring, whirring, waterfall

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Venous Hum versus Pathologic Continuous Murmurs

❖ PDA

❖ Coronary fistula

❖ Cranial AVM

❖ AO-‐PA shunt

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Innocent Murmur: Peripheral Pulmonary Stenosis

❖ PPS in infant under 6 mos: same pitch as respirations

❖ As loud or loudest in back or axilla

❖ Systolic, high pitched, blowing

❖ Relatively small branch Pas arising at acute angle from large MPA

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PPS versus Pathologic Murmurs

PPS-‐distinguish from

❖ Tiny VSD: better heard at mid to LLSB, not back/axilla

❖ PS: has a click

❖ ASD: Has abnl S2

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Position Changes

❖ Distinguish innocent Still’s murmurs from LVOTO ❖ Detect gallops: apex, left lateral decubitus ❖ Distinguish venous hums from non-‐innocent

continuous murmurs ❖ Mitral valve prolapse

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Mitral Valve Prolapse

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Auscultation

Artificial valves: should be audible without a stethoscope

★ Artificial aortic valves should have a mechanical S2

★ Artificial mitral valves should have a mechanical S1

★ Worry if it goes away-‐valve thrombosis

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Tips for better exams

❖ Quiet room ❖ Recognize that naptime, stranger anxiety, hunger

can adversely affect the situation ❖ Make the child as comfortable as possible: ❖ Silent distracters to entertain the child-‐flashlight, ID

badge, toys, siblings

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Tips for Better Exams

★ Tiny bodies: Use the right size stethoscope to minimize ambient noise and to accurately determine the presence and location of a murmur

★ Change the order of the exam to fit the child ★ Warm hands and scopes

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★ Remember-‐

★ Always not normal: RV impulse, thrills, apical murmurs, murmurs that increase with sitting or standing, murmurs with extra heart sounds, diastolic murmurs

★ Need to have a normally split S2 to be normal

★ If it does not sound innocent-‐ needs further evaluation

★ Thank you.

Documents

TCH APP Conference April 2019multitonal) 34 CongenitalHeartDefects Atrial&Septal&Defect& Patent&Ductus&Arteriosus& Ventricular&Septal&Defect& PulmonaryStenosis Aortic&Stenosis 35 CHD:AtrialSeptalDefect