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New Treatments for Heart Murmurs in Children

Characteristics of innocent murmurs; well, they usually have a normal history and physical exam other than the murmur. There are no other signs of heart failure or heart pathology. They are not cyanotic. The amplitude is usually 1 or 2, but can be as high as 3. And the amplitude often will vary with position. If it’s a grade 4 murmur, meaning you can feel a thrill, then it almost has to be pathologic. In fact, it does have to be pathologic. They are usually early or mid-systolic ejection murmurs. They are never diastolic alone. The quality of these murmurs is usually soft or vibratory, often referred to as musical when you are talking about a Still’s murmur. It should not be harsh.

Flow murmurs are usually short, soft or blowing. They are usually a grade 1 or grade 2. They can be vibratory but they are usually, even when they are vibratory, not a grade 3 and they will usually change with position or with Valsalva maneuvers. With a Valsalva maneuver you decrease your flow and so it should get softer or quieter, or even go away all together. Peripheral pulmonic stenosis is an innocent murmur in infants or neonates and the hallmark of this is that the murmur will be larger in the axilla, either left or right, than it is centrally. This is a normal finding in an infant usually less than a year of age. In an older child it’s very rare to have a pathologic peripheral pulmonic stenosis but it is associated with certain diseases.

There are no innocent diastolic murmurs. So if you hear a diastolic murmur, it’s pathologic until proven otherwise and then you can write me about it. Pathologic associations with systolic murmurs, a systolic murmur at the right upper sternal border, or apex, is usually the aortic position usually associated with either aortic stenosis or subaortic stenosis. In the case of aortic stenosis it’s usually a harsh murmur, it radiates well across the arch so into the carotids.

Continuing with systolic murmurs; the left upper sternal border is the pulmonary position. Pulmonic stenosis will cause a crescendo/decrescendo murmur associated often with a valve click, but not always. It’s also where you would hear the murmur of tetralogy of Fallot which will usually have a single second heart sound. Again, peripheral pneumonic stenosis best heard in the _ infants. An atrial septal defect will have what sounds like a flow murmur.

Lower sternum or apex of the heart; usually these are holosystolic murmurs representing a ventricular septal defect or mitral regurgitation. In the case of mitral valve prolapse it is not necessarily holosystolic. Often there will be some silence followed by a click and then a harsh murmur. This murmur is often described as a "whoop" or a "honk". I’m not sure why but in a lot of textbooks and sometimes in standardized tests it will be described like that. Then continuous murmurs; PDA has a harsh "washing machine" type quality and AV malformations with the other pathologic cause of continuous murmurs usually exist in the head or the abdomen; either in the liver or the kidneys, so the murmur would be loudest over the arteriovenous malformation.

Pathologic murmurs; aortic insufficiency, which is usually associated with bicuspid aortic valve and degeneration, causes an early blowing decrescendo murmur. It may be associated with a ventricular septal defect if the defect is close enough to the aortic valve that it causes damage to the aortic valve. Pulmonary insufficiency is most commonly seen following repair of tetralogy.

Differential diagnosis of murmurs in athletes; like I mentioned before, if you hear a murmur in an athlete you need to specifically rule out asymptomatic aortic stenosis and/or hypertrophic cardiomyopathy because this is the most commonly associated lesion in sudden death in athletes. If you get an ECG on them you will see left ventricular hypertrophy with a strain pattern.