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Accidental Heart Murmurs Doi: 10.5455/Medarh.2017.71.284-287 Edin Begic1, Zijo Begic2 MED ARCH

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Accidental Heart Murmurs Doi: 10.5455/Medarh.2017.71.284-287 Edin Begic1, Zijo Begic2 MED ARCH REVIEW Accidental Heart Murmurs doi: 10.5455/medarh.2017.71.284-287 Edin Begic1, Zijo Begic2 MED ARCH. 2017 AUG; 71(4): 284-287 RECEIVED: JUN 20, 2017 | ACCEPTED: AUG 01, 2017 ABSTRACT Introduction: Accidental murmurs occur in anatomically and physiologically normal heart. Ac- cidental (innocent) murmurs have their own clearly defined clinical characteristics (asymp- tomatic, they require minimal follow-up care). Aim: To point out the significance of ausculta- 1Faculty of Medicine, Sarajevo School of Science and tion of the heart in the differentiation of heart murmurs and show clinical characteristics of Technology, Sarajevo, Bosnia and Herzegovina accidental heart murmurs. Material and methods: Article presents review of literature which 2Pediatric Clinic, University Clinical Center Sarajevo, deals with the issue of accidental heart murmurs in the pediatric cardiology. Results: In the Sarajevo, Bosnia and Herzegovina group of accidental murmurs we include classic vibratory parasternal-precordial Stills mur- mur, pulmonary ejection murmur, the systolic murmur of pulmonary flow in neonates, venous Corresponding author: Edin Begic, MD. Faculty of hum, carotid bruit, Potaine murmur, benign cephalic murmur and mammary souffle. Con- Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina. ORCID ID: http:// clusion: Accidental heart murmurs are revealed by auscultation in over 50% of children and www.orcid.org/0000-0001-6842-262X. E-mail: youth, with a peak occurrence between 3-6 years or 8-12 years of life. Reducing the frequency [email protected]. 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. Keywords: heart murmurs, accidental heart murmurs, heart auscultation. 1. INTRODUCTION vascular structure. The pathologic Heart murmurs can be organic substrate is a change from laminar (sign of heart disease) and inorgan- to turbulent flow. Incomplete open- ic (usually called innocent; basically ing of the aortic valve during systole divided into accidental and function- gives a triangular appearance of the al) (1). Accidental murmurs occur aortic valve lumen and tension of the in anatomically and physiologically valve, and thus converting laminar normal heart. Some authors may dif- blood flow to turbulent flow with the fer them from functional (murmurs vibration of valves and surrounding occurring in diseases which second- wall structures (1, 2). The transfer of arily affect the heart), but they are valve vibrations in the wall caused often involved in group of common by tribulation, probably represents innocent murmurs. With sufficient the physical background for etiolo- knowledge, it is possible to differ- gy of these murmurs. This change is entiate accidental and functional not only developed because of tri- murmur, just by auscultation. The gonidation (inconsistency or vola- localisation of accidental murmurs tility) of the valve, but also because is distributed in the precordium, of the flow of the blood through most often with left edge of ster- large vessels, which vary in size and num. Accidental (innocent) mur- diameter. Insufficient elasticity of murs have their own clearly defined valves leads to the incomplete open- clinical characteristics (asymptom- ing of the pulmonic or aortic valve, atic, they require minimal follow-up with a so-called triangular form of care) (1). They occur in anatomical- valve opening, which leads to tur- ly and physiologically normal heart. bulence outside the normal laminar They are called innocent, harmless, flow and flickering/trembling of the physiological, irrelevant, evolving, valve, which produces the murmur. benign, habitual, infantile, growth When they appear on semilunar murmurs, accidental, non-patho- valves (pulmonary and aortic valve), logical, non-organic, normal, false, for the development of murmur meaningless, ‘’functional’’, supine the tendon fibers of atrioventricu- © 2017 Edin Begic, Zijo Begic position murmurs, nonsignificant, lar valves are primarily responsible transitory, dynamic. Their place of (3, 4). The common background for This is an Open Access article distributed under the origin may not be the same, but they development of accidental murmurs terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/ are most commonly associated with presents interaction of turbulency, licenses/by-nc/4.0/) which permits unrestricted non- aortic and pulmonary valve (trigo- vibrations of valves and limited di- commercial use, distribution, and reproduction in any nodation with systole) and turbu- mensions of wall structures. Today it medium, provided the original work is properly cited. lent bloodflow within cardiac and is possible with echocardiographical 284 REVIEW | MED ARCH. 2017 AUG; 71(4): 284-287 Accidental Heart Murmurs aproach to visualise the symmetry within the structure and abnormal heart positions (7, 8). It is seen in school- of pulmonary and aortic valve (bicuspid, instead of tri- aged kids, and puberty and probably developed due to cuspid semilunar valves). Probably the most common normal turbulency of blood to the pulmonary valve. It is places for development of accidental murmurs are tend- less common than Still’s murmur, best heard in second inious fibers (chorde tendinae) of atrioventricular valves, and third intercostal space on the left, in lying position, so-called atypical or accessory tendinious fibers. Finally, probably due to increased stroke volume and ejection there are also tendinious fibers (chorde tendinae) which of blood. This murmur shows a significant increase of are completely atypical and are present in the left ventri- incidence, in deference to Still murmur, in cases of in- cle, and they do not communicate with atrioventricular creased cardiac output, but we should keep in mind that valve. both types of murmurs are increasing the frequency. It is When that kind of atypical chordae is placed in a posi- briefly transmitted parasternaly and toward heart apex. tion with normal blood flow, it produces a murmur sim- Pulmonary components of 2nd heart sound are normal. ilar to harp, which has a high frequency and produces a It is frequently seen in adolescents and it is the most com- very typical musical murmur, around the lower left edge mon accidental murmur in this age. Based on duration, it of sternum (so-called Still’s murmur) (5). is included in the first part of systole, when the speed of There is no dependency between localisation of acces- systole ejection is at its maximum. Fast flow through an sory chordae and maximal point of earshot of that mur- exit tract of the right ventricle, which is relatively super- mur. ficial leads to trgonization/inconsistency of pulmonary cusps. Usually, the murmur is louder, when the patient 2. AIM is in a lying position, and after laying stress/overload, be- To point out the significance of auscultation of the cause of an increase in venous flow and stroke volume of heart in the differentiation of heart murmurs and show the right ventricle. It is possible that murmur develops clinical characteristics of accidental heart murmurs. due to compression of pulmonary artery with following increase of cardiac phase and cardiac ejection. 3. MATERIAL AND METHODS The systolic murmur of pulmonary flow in neonates Article presents review of literature which deals with (physiological murmur of pulmonary stenosis in ne- the issue of accidental heart murmurs in the pediatric onates) most commonly is lost on end of the second cardiology. month of life (present in premature babies and neonates). It is ejection type, 1st or 2nd degree by Levine, and heard 4. RESULTS on both sides on the bases of heart with propagation to Classic vibratory parasternal–precordial Stills exile and the back. Short, usually developed due to tur- murmur (described by Still in 1918) is a systolic ejec- bulence of blood on bifurcation of the pulmonary artery. tion murmur which constitutes over 50% of all accidental This is the weakest, by intensity, systolic murmur and murmurs, best heard in area between ictus and lower left best audible on the base of the heart, in exile, under arm- edge of sternum (maximal puncture is most common- pits and in the back, on both sides. ly between 3rd and 4th intercostal space, on the left), Venous hum (cervical venous hum, spindle mur- usual intensity is between 2nd and 3rd degree based on mur) represents continuous murmur which may appear Levine’s scale low-freqency, with duration in the first half like profound silent and soft humming, with maximal or first two thirds of systole, by the quality it can be musi- audibility in systole. It is auscultated with fast blood flow, cal, vibratory, buzzing, pinking, blubbering/sobbing (6). from the jugular vein into superior vena cavae, within the Sometimes the murmur may radiate towards exile. Most right edge of the manubrium of the sternum, although it frequently it is seen in children of preschool age, between can be auscultated on the left in second intercostal space the age of 3 to 7, it is increased with states of tachycardia, (9). overload states, and is more audible/perceptible in lying It is also heard on the right with the neck, and on the position. It correlates with presence of aberrant chordae front part of the thorax (above and below the clavicle). in depth of left ventricle (36%). It is the most common Maximal pointer is sometimes located just below right of all accidental murmurs. McKusic considers that the clavicle. These murmurs are usually seen in anemic pa- cause of these murmurs is trigonization/inconsistency tients, and are most prominent in sitting position and of pulmonary cusps in systole. Some studies show that loosing on intensity, and nearly stoping in lying position. parasternal-precordial murmurs may be third, or even They are completely absent during the compression of fourth degree, based on intensity, when is also possible jugular veins in the neck.
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