Children with heart murmurs: can ventricular septal defect be diagnosed reliably without an echocardiogram?

Assessment of Tricuspid Valve Detachment Efficiency for Ventricular Septal Defect Closure: A Retrospective Comparative Study

Background

The aim of this study was to investigate the efficiency of tricuspid valve detachment (TVD) during the surgical treatment of perimembranous ventricular septal defects (VSDs) and to compare the early and mid-term results to patients without TVD in terms of tricuspid insufficiency.

Methods

A total of 170 patients who had undergone surgical closure of perimembranous VSDs between November 2012 and January 2019 were included in this study, of whom 50 had an additional TVD procedure during the surgery. All patients were examined by transthoracic echocardiography before and after the operation with regular intervals, and the tricuspid valve function was then evaluated.

Results

There was no significant difference between subgroups with an unchanging degree of TVR, however, the result was also similar among those who had a decreased degree of TVR at any level (p = 0.271, p = 0.451). At the end of the study, all patients were in New York Heart Association class I.

Conclusions

We suggest that, in appropriate patients, VSD closure can be safely performed with an additional TVD application through an incision of the septal leaflet of the tricuspid valve without impairing the valve function or reducing the growth potential of the valve at midterm follow-up.

Estimating pressure gradients by auscultation: How technology (echocardiography) can help improve clinical skills

AIM

To extend our previously-published experience in estimating pressure gradients (PG) via physical examination in a large patient cohort.

METHODS

From January 1, 1997 through December 31, 2009, an attending pediatric cardiologist compared clinical examination (EXAM) with Doppler-echo (ECHO), in 1193 patients with pulmonic stenosis (PS, including tetralogy of Fallot), aortic stenosis (AS), and ventricular septal defect (VSD). EXAM PG estimates were based primarily on a murmur’s pitch, grade, and length. ECHO peak instantaneous PG was derived from the modified Bernoulli equation. Patients were 0-38.4 years old (median 4.8).

RESULTS

For all patients, EXAM correlated highly with ECHO: ECHO = 0.99 (EXAM) + 3.2 mmHg; r = +0.89; P < 0.0001. Agreement was excellent (mean difference = -2.9 ± 16.1 mmHg). In 78% of all patients, agreement between EXAM and ECHO was within 15 mmHg and within 5 mmHg in 45%. Clinical estimates of PS PG were more accurate than of AS and VSD. A palpable precordial thrill and increasing loudness of the murmur predicted higher gradients (P < 0.0001). Weight did not influence accuracy. A learning curve was evident, such that the most recent quartile of patients showed ECHO = 1.01 (EXAM) + 1.9, r = +0.92, P < 0.0001; during this time, the attending pediatric cardiologist had been > 10 years in practice.

CONCLUSION

Clinical examination can accurately estimate PG in PS, AS, or VSD. Continual correlation of clinical findings with echocardiography can lead to highly accurate diagnostic skills.

Discordance between data acquired by history and findings of physical examination: a phenomenal paradox

BACKGROUND

History and physical examination are the basis of any diagnosis. The findings of the physical examination usually corroborate the thoughts generated by the medical history. However, it is not uncommon for the physician to note discrepancies between the history and the physical examination.

METHODS

Two physicians provided a list of diseases they have encountered in which there is occasionally discordance between the data retrieved from the patient's medical history and the findings of the physical examination. To verify the data from knowledge and experience, we resorted to two main medical textbooks and relevant articles from PubMed.

RESULTS

We identified 25 diseases where a discordance between history and physical examination may frequently be observed. These diseases cover a wide spectrum of systems (i.e., neurological, cardiological, respiratory, and gastrointestinal).

DISCUSSION

A variety of diseases are associated with a discordance between the findings one might expect based on the medical history and the actual findings of the physical examination. Physicians need to be aware of this paradox, as misdiagnosis can be detrimental in some of these diseases. We acknowledge that this is just a sample, and not an exhaustive list, of all diseases with such a discordance.

Phono-spectrographic analysis of heart murmur in children

BACKGROUND

More than 90% of heart murmurs in children are innocent. Frequently the skills of the first examiner are not adequate to differentiate between innocent and pathological murmurs. Our goal was to evaluate the value of a simple and low-cost phonocardiographic recording and analysis system in determining the characteristic features of heart murmurs in children and in distinguishing innocent systolic murmurs from pathological.

METHODS

The system consisting of an electronic stethoscope and a multimedia laptop computer was used for the recording, monitoring and analysis of auscultation findings. The recorded sounds were examined graphically and numerically using combined phono-spectrograms. The data consisted of heart sound recordings from 807 pediatric patients, including 88 normal cases without any murmur, 447 innocent murmurs and 272 pathological murmurs. The phono-spectrographic features of heart murmurs were examined visually and numerically. From this database, 50 innocent vibratory murmurs, 25 innocent ejection murmurs and 50 easily confusable, mildly pathological systolic murmurs were selected to test whether quantitative phono-spectrographic analysis could be used as an accurate screening tool for systolic heart murmurs in children.

RESULTS

The phono-spectrograms of the most common innocent and pathological murmurs were presented as examples of the whole data set. Typically, innocent murmurs had lower frequencies (below 200 Hz) and a frequency spectrum with a more harmonic structure than pathological cases. Quantitative analysis revealed no significant differences in the duration of S1 and S2 or loudness of systolic murmurs between the pathological and physiological systolic murmurs. However, the pathological murmurs included both lower and higher frequencies than the physiological ones (p < 0.001 for both low and high frequency limits). If the systolic murmur contained intensive frequency components of over 200 Hz, or its length accounted for over 80 % of the whole systolic duration, it was considered pathological. Using these criteria, 90 % specificity and 91 % sensitivity in screening were achieved.

CONCLUSION

Phono-spectrographic analysis improves the accuracy of primary heart murmur evaluation and educates inexperienced listener. Using simple quantitative criterias a level of pediatric cardiologist is easily achieved in screening heart murmurs in children.

Cardiac murmurs: echocardiography in the assessment of patients requiring antibiotic prophylaxis for dental treatment

BACKGROUND

Traditionally patients who indicate that they have a heart murmur or who indicate that they have had rheumatic fever are given antibiotic prophylaxis for dental treatment. This is commonly done without further assessment of the patient's actual endocarditis risk. Echocardiography is a non-invasive method of assessing cardiac valve function and haemodynamics.

METHODS

Consecutive patients who were referred to a private practice oral and maxillofacial surgeon for dentoalveolar surgery and indicated that they had a cardiac problem and usually had antibiotic prophylaxis, were evaluated. Those with a clear indication for prophylaxis, for example had prosthetic heart valves or previous infective endocarditis, received antibiotic prophylaxis. Where there was uncertainty, they were referred for an echocardiogram, and if abnormal, a formal cardiology review.

RESULTS

Three hundred and seventy patients out of approximately 20 000 (1.85 per cent) indicated that they had a cardiac murmur and usually received antibiotic prophylaxis for dental treatment between 1 February 1997 and 1 February 2005. Two hundred and sixty-two (71 per cent) were female and 108 (29 per cent) were male; age range 0.7 to 98 years, average 37.6 years. Two hundred and seventy (72 per cent) had normal hearts with no indication for antibiotic prophylaxis. Of the 100 (28 per cent) patients with abnormal findings, they were on average older; 49.5 years, range 0.7 to 87 years. Of these, 50 (14 per cent) met current indications for antibiotic prophylaxis.

CONCLUSION

Patients who present for dental treatment indicating that they require antibiotic prophylaxis for cardiac condition need to be fully evaluated. In this study only 50 of 370 patients (14 per cent) required antibiotic prophylaxis. The remaining 320 (86 per cent) would have no benefit but a risk of adverse reaction to the antibiotic.

Optimizing utilization of pediatric echocardiography and implications for telemedicine

Telemedicine can deliver tertiary level services to remote communities where subspecialty care is limited. Locally performed echocardiography has been initiated at several locations around Iowa. The goal of this study was to examine utilization and diagnostic yield of community-based echocardiographic services. Community physicians selected patients for remote echocardiograms (echoes), and studies were performed locally by sonographers trained in recording pediatric echoes. Echoes were sent to the pediatric echocardiography laboratory by mail or via telemedicine systems. Echoes were also ordered locally by pediatric cardiologists during outreach clinics in the same communities. Numbers of normal and abnormal echoes ordered by community physicions and pediatric cardiologists were compared by chi-square analysis. Since January 1996, community physicians ordered 378 echoes, whereas 154 echoes were ordered by pediatric cardiologists at outreach clinics. Stratifying echoes by patient age found that the percentage of normal studies in patients < 1 year of age was no different between groups (27% normal by community physicians vs 15%; chi-square 0.92; p = 0.34). The percentage of normal studies ordered by community physicians was significantly greater in patients > 1 year of age (83% normal by community physicians vs 25%; chi-square 80.2; p <0.0001). Thus, (1) community physicians effectively identified patients < 1 year of age with abnormal echoes, (2) significantly fewer echoes may be required in patients > 1 year of age if patients are first evaluated by a pediatric cardiologist, and (3) patient selection will impact cost effectiveness of remotely obtained echoes.

Pulmonary stenosis: defect-specific diagnostic accuracy of heart murmurs in children

OBJECTIVE

To determine the accuracy of expert examination for pulmonary stenosis (PS) among children with murmur.

STUDY DESIGN

Five hundred twenty-one consecutive, previously unevaluated, pediatric patients were enrolled. The investigators prospectively recorded their diagnosis and level of confidence, categorizing any PS suspected as mild or severe. After echocardiography, PS was categorized by severity with peak systolic flow velocity. Receiver operating characteristic curves described accuracy of clinical examination.

RESULTS

Sixty-two patients had PS (mild, 29; moderate, 27; and severe, 6). Receiver operator characteristic curve areas were: total, 0.834 +/- 0.033; mild, 0.862 +/- 0.044; and moderate to severe, 0.809 +/- 0.046 (P =.20). Specific difficulties in discrimination of PS from small ventricular septal defect, aortic valve disease, atrial septal defect, and innocent murmur were identified. All cases of severe PS in which PS was suspected were thought possibly severe.

CONCLUSIONS

Although expert clinical examination is highly accurate for distinguishing PS from non-PS cardiac murmurs in pediatric patients, it is imperfect.