What makes a heart murmur innocent?

Accidental Heart Murmurs

INTRODUCTION

Accidental murmurs occur in anatomically and physiologically normal heart. Accidental (innocent) murmurs have their own clearly defined clinical characteristics (asymptomatic, they require minimal follow-up care).

AIM

To point out the significance of auscultation of the heart in the differentiation of heart murmurs and show clinical characteristics of accidental heart murmurs.

MATERIAL AND METHODS

Article presents review of literature which deals with the issue of accidental heart murmurs in the pediatric cardiology.

RESULTS

In the group of accidental murmurs we include classic vibratory parasternal-precordial Stills murmur, pulmonary ejection murmur, the systolic murmur of pulmonary flow in neonates, venous hum, carotid bruit, Potaine murmur, benign cephalic murmur and mammary souffle.

CONCLUSION

Accidental heart murmurs are revealed by auscultation in over 50% of children and youth, with a peak occurrence between 3-6 years or 8-12 years of life. Reducing the frequency of murmurs in the later period can be related to poor conduction of the murmur, although the disappearance of murmur in principle is not expected. It is the most common reason of cardiac treatment of the child, and is a common cause of unreasonable concern of parents.

Evaluation of Congenital Heart Defects Treatment Options-Establishment of Pediatric Cardiology/Cardiosurgery in Bosnia and Herzegovina

INTRODUCTION

Modern pediatric cardiology mainly deals with congenital heart defects (CHD), as the most common congenital anomalies. In most cases CHD requires surgical or interventional treatment.

GOAL

The goal of the research was to evaluate CHD treatment at Pediatric Clinic, University Clinical Center (UCC) Sarajevo, Bosnia and Herzegovina (B&H). UCC Sarajevo is the only institution in B&H where cardiac treatment of CHD in pediatric population is performed. Pediatric cardiosurgery has started to develop in Bosnia and Herzegovina in April 1997.

PATIENTS AND METHODS

Study included 745 patients (period from April 1997 to January 2017).

RESULTS

Cardiac treatment was performed on 745 patients with CHD, 541 (72.6%) of them were acyanotic patients and 204 (27.4%) were cyanotic patients. Reoperation was performed in 49 (6.5%) of patients. Out of total number of patients, 59 (7.9%) died. In 660 children (88.5%) a complete correction and in 85 (11.5%) a palliative operation/correction was performed. Defects with left to right shunt were present in 397 (53.2%) patients, complex heart defects with Tetralogy of Fallot in 173 (23.2%), obstructive heart defects in 106 (14.2%), obstructive heart defects with shunt in 53 (7.1%), and others in 16 (2.1%) of patients. During surgery, extracorporeal circulation was regulated in 554 (74.3%) patients. Peri and early postoperative complications occurred in 180 (24.1%) of patients. During this period 24 pacemakers were implanted and 24 radiofrequency ablations were performed.

CONCLUSION

Results of CHD cardiac treatment in childhood, which took place simultaneously, followed by the contractual joint programs and individual work of the Bosnian and Herzegovinian team has reached the highest level in the last two years, not only by the number, type and complexity of corrected CHD, but also by the age and body weight of the patients who underwent surgery, and development of invasive procedures, arrhytmology, pacemaker placement, intensive peri and postoperative treatment. That led pediatric cardiac surgery of UCC Sarajevo, to a position of leading center in the region.

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.

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.