[Heart murmurs in asymptomatic children: When should you refer?]

A Study on Clinical Screening of Neonatal Congenital Heart Disease in Jinjiang City

OBJECTIVE

This study explored the feasibility of congenital heart disease (CHD) screening by combining a percutaneous oxygen saturation (POX) test with cardiac auscultation method in neonates.

METHODS

POX tests and cardiac auscultation were used concurrently to screen 8305 neonates born in Jinjiang City Hospital between January 2016 and December 2018 for CHD. The positive screening results (positive POX or positive cardiac auscultation) were confirmed with echocardiography, while any false negative results were identified through follow-up and parent feedback. Sensitivity, specificity, positive/negative predictive values, Youden's index, and the area under the receiver operator characteristic curve (AUC) of the single use and combined use of the two methods (a POX test and auscultation) were calculated, and the results were compared.

RESULTS

Among 8305 neonates, 22 cases were positive for POX alone, of which 6 cases were diagnosed by echocardiography; 83 cases were positive for cardiac auscultation alone, of which 47 cases were diagnosed by echocardiography; and 8 cases were positive for both methods, all of which were confirmed by echocardiography. Four more cases were confirmed during follow-up. Sensitivity, specificity, and the positive and negative predictive values of combined screening were 93.85%, 99.37%, 53.98% and 99.95%, respectively, while Youden's index was 0.93, and the AUC was 0.966. Sixty-five cases of CHD were diagnosed, the total incidence being 7.82%, and a ventricular septal defect was found to be the most common type.

CONCLUSION

The combination of POX test and cardiac auscultation as a screening method for neonatal CHD can reduce missed diagnoses and increase the detection rate of CHD in newborn infants.

Age when presumptive innocent cardiac murmurs spontaneously disappear in clinically healthy Cairn terrier puppies

Innocent cardiac murmurs are common findings in Cairn terrier puppies during their first veterinary health check. The age when these murmurs spontaneously disappear is unreported. The purpose of this study was to establish the age when presumably innocent cardiac murmurs disappear in a population of clinically healthy Cairn terrier puppies. Over a period of 9 months, 227 clinically healthy Cairn terrier puppies (median age, 53 days; range, 45-76 days) underwent auscultation by a veterinary cardiology specialist, who identified 82 puppies with a presumably innocent cardiac murmur. Owners of 20 puppies volunteered to return to the clinic for serial rechecks. Owners of three puppies returned only once, therefore these puppies were censored. Hence this longitudinal observational study followed 17 puppies with monthly cardiac auscultation until the disappearance of their murmurs. The median age of the 20 puppies when the murmur was last audible was 65 days (range 52-285 days). The median age of the 17 puppies when the murmur was no longer audible was 87 days (range 71-347 days; 95% confidence interval 63-111 days). Four of the 17 puppies had a murmur after 3 months of age and two of them had a murmur beyond 6 months of age. The oldest puppy to have an audible murmur was 9.5 months old; this murmur was not audible at 11.5 months of age. In most Cairn terrier puppies in this population, the presumably innocent murmur resolved spontaneously by 3 months of age.

Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children

PURPOSE

The distinction between physiologic (innocent) and pathologic (organic) heart murmurs is not always easy in routine practice, leading too often to unnecessary cardiology referrals and expensive investigations. We aimed to test the hypothesis that the complete disappearance of murmur on standing can exclude cardiac disease in children.

METHODS

From January 2014 to January 2015, we prospectively included 194 consecutive children aged 2 to 18 years who were referred for heart murmur evaluation to pediatric cardiologists at 2 French medical centers. Heart murmur characteristics while supine and then while standing were recorded, and an echo-cardiogram was performed.

RESULTS

Overall, 30 (15%) of the 194 children had a pathologic heart murmur as determined by an abnormal echocardiogram. Among the 100 children (51%) who had a murmur that was present while they were supine but completely disappeared when they stood up, only 2 had a pathologic murmur, and just 1 of them needed further evaluation. Complete disappearance of the heart murmur on standing therefore excluded a pathologic murmur with a high positive predictive value of 98% and specificity of 93%, albeit with a lower sensitivity of 60%.

CONCLUSIONS

Disappearance of a heart murmur on standing is a reliable clinical tool for ruling out pathologic heart murmurs in children aged 2 years and older. This basic clinical assessment would avoid many unnecessary referrals to cardiologists.

Evaluation of Diagnostic Methods in the Differentiation of Heart Murmurs in Children

Introduction:

The most common clinical sign in pediatric cardiology is a heart murmur (organic and inorganic). Organic are sign of heart disease, while inorganic (basically divided into accidental and functional) murmurs occur on anatomically healthy heart.

Aim:

To determine the justification of the application of the methods of cardiac treatment.

Patients and methods:

Study included 116 children aged from 1 to 15 years, who were referred due to cardiac treatment to Pediatric Clinic, of Sarajevo University Clinical Center.

Results:

The first group consisted of children with innocent heart murmur, 97 (53 males). The second group consisted of patients with organic murmur, 19 (13 males). The average age of the first group was 7.69 (1.01–15.01) years old, and of the second group 3.15 (1.01- 8.06) years old, and there is a significant difference between these two groups (p <0.001). Medical history questions about potentially harmful habits of mother in pregnancy, found significant differences in the frequency of the existence of habits between the first and second groups of subjects (14.44% vs. 85.1%, p = 0.013). The values of the pulse of patients showed statistically significant difference (p = 0.012). The most common place of the murmurs’ appearance is the second left intercostal space. In the first group, the most common were vibratory (32.3%) and ejection (31.9%) and in the second the most common were holosystolic (73.7%) murmur. Analyzing the R/S ratio of V1, a significant difference among the two groups was found (mean 0.78 vs. the values for 1.45, p = 0.003). There is a significance in terms of developed hypertrophy of the heart cavities (BVH) between the two groups. The most common accidental murmur was classic vibratory Still’s murmurs (55.43%) and the most common congenital heart defects was ASD (36.8%).

Conclusions:

A heart murmur itself, should not be the purpose of auscultation. One of the tasks of pediatricians, pediatric cardiologists in particular would be to improve auscultation, as a sovereign method of heart murmurs assessment. Heart murmur assessment should be adapted to recognize whether heart murmur is innocent, or there is suspected or probable congenital heart defect.