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 . 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 , 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 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 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 , (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 in the neck. Sometimes it is enough just to to register a following thrill. compress the vein with your thumb, in order to change Pulmonary ejection murmur (physiological systol- or too loose, previously found systolic-diastolic mur- ic) is the second most common innocent murmur, often mur. After turning the head in the opposite position, it heard at the base of the heart, to the left. In its character enhances. Murmurs are, by quality, the closest to deep it is blowing to the third degree of loudness/volume. It is silence, and soft humming /(differential diagnosis with more harsh than Still’s murmur, increased with tachycar- murmur PDA). In extremely rare cases it can give the dia and it is the loudest in lying position. It is common thrill. Most commonly it appears in preschool age, with in kids with deformities of thorax, pectus excavatum, the greatest prevalence in kids between age 3 to 8. kyphoscoliosis, flat back syndrome, with obese children

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Localisation and type of murmur Can be confused for Deifferences between accidental murmus 2nd and 3rd intercostal space, Fixed and ripped 2nd tone; murmur is louder than 2nd and 3rd degree and longer ASD on the left (pulm. ejection systol- duration with possible thrill; present ejection click, pulmonary component of 2nd Pulmonary stenosis (PS) ic murmur) tone weakned. Irradiates to back and axillas Most commonly a loud murmur, harsh, high in frequency, regruitating, holosystolic, 3rd and 4th intercostal space Ventricular septal defect with possible thrill, and strong propagation. Erb or ictus (Still’s vibratory (VSD) Quiet first tone, murmur is holosystolic, variable, with thrill, bloowing or whooping murmur) Mitral insuficiency character. The murmur is usually loud, harsh, ejaction, with thrill, with wide irradiation to jugular 2nd intercostal space, on right Aortic stenosis and carotids, thus ictus. Ejection click is present. (systolic murmur, with pulmo- Coarctation of aorta Atypical murmur, comonly audible on the back, and around left clavicle (non-palpa- nary flow, or carotid murmur) blity of femoral , hypertension). Patent ductus arteriosus The maximum of the murmur is on the second tone, which is comonly not audible. No 2nd intercostal space on right (PDA) change in loudness with change of body position. Posible thrill, with jumping . and left(venous hum) Peripheral PS Murmurs heard all over thorax 2nd intercostal space, left The murmur is often louder, more harsh, longer duration and expanding towards andr right, along neck (arterial Aortic stenosis heart apex aand jugulum. Ejection click, possible thrill. supraclavicular murmur) Table 1. Differential diagnosis of accidental murmurs in children (6, 7, 14-19)

Carotid bruit (arterial supraclavicular vascular 5. DISCUSSION murmur, arterial murmur of neck blood vessels) is Differentially - diagnostically analyzed (Table 1) ac- presented either above or below the clavicle on the right cidental murmurs of vibratory and pulmonary systolic side, and it is transmitted to the bases (9). In overload - ejection character may be replaced with murmurs of states it gets louder, and a change in body position or organic origin in aortic stenosis, pulmonary stenosis, respirations do not affect it. It is seen in proto or meso atrial septal defect (ASD). Supraclavicular or carotid- systole. Usually is short, commonly quiet, but it can be ic murmur can often be replaced with the murmur of louder up to 4th degree of Levins scale, occasionally is aortic stenosis, coarctation, carotid stenosis, stenosis palpable the thrill over carotid. Gets softer or lost with of the subclavian artery. Venous hum can often imitate Hyperextension of the shoulders or compression of ca- the sound of murmur of persistent ductus arteriosus or rotid on that side. Probably caused by turbulent blood arterio-venous fistulae. If you have enough experience, flow in the exit parts of the great blood vessels in the it is possible to differentiate accidental and functional aortic arch, thus when blood from the aorta in systole is murmur by auscultation. Still’s murmur may be replaced re-directed to brachycephalic trunk and into the left ca- with murmur of mitral insufficiency, accidental murmur rotid artery. Usually audible over clavicles, more present- over the pulmonary artery with defect of the interatrial ed on the right side. Can present the problem with dif- septum or partial anomalous pulmonary vein or vein, but ferential diagnosing towards murmur of aortic stenosis. in these cases doubts may be avoided if it is known that Cardiopulmonary murmurs (Potaine) develops on the aforementioned cardiac anomalies are characterized parts of lungs close to the heart, from which air is ex- by accentuated and fixedly agitated other tone. Assis- pelled with contractions. This is the way the high-fre- tance in differential diagnosis can certainly provide an quency high-pitched murmur occurs, which is mainly electrocardiogram, X-ray examination and ultrasound audible over on heart to lung border, almost scan. The characteristics of these murmurs are that they always just in one particular place, and its loudness is are purely systolic, maximally affecting up to 60% of the changed with respirations. It is superficial, audible only systole, usually occur in early systole, are separated from in inspiring, and best heard at heart apex. These mur- both tons, with relatively shorter duration, with poor murs are almost always systolic and may vary in inten- propagation (where they occur and die), and are mainly sity, in dependance with respirations. Probably develops of ejection (extrusion) type. Most often in intensity they because of friction between heart and lung tissue. The are between the first and second degree, and very rare murmur is not synchronised with heartbeats, and com- of third. They can be best heard on the left sternal edge monly heard in the middle of systole, from first tone. of the patient in the lying position. By shape they are Starts abruptly, with narrow localisation and heard as ascending-descending (crescendo-decrescendo).. They chanting. are variable and change during respiration and body Benign cephalic murmur is presented during the first position change (4). They are amplified after loading or ten years of life, with low frequency, continuity, but in inhaling amyl nitrate, and are rarely encountered in the the least number of cases may be systolic. By localisation, newborn and younger infants. They are not associated in form with upper part of thorax and neck. with other clinical signs of heart disease (10, 11, 18, 19). Mammary souffle is murmured with continuity, au- They are more gentle in the inspiration when the patient dible around mammary blood vessels, presented by ad- is sitting or standing. Murmurs are most often musical, olescent persons. soft with a frequency of oscillation of about 200 hertz.

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The amplitude maximum is in the early systole, and form 6. Alpert MA. Systolic Murmurs. In: Walker HK, Hall WD, of murmur is spindle-shaped. They are best audible in Hurst JW, editors. Clinical Methods: The History, Physical, the supine position. Intensity is reduced with Valsalva and Laboratory Examinations. 3rd edition. Boston: Butter- maneuver. They are not associated with ejection clicks or worths; 1990. Chapter 26. Available from: https://www.ncbi. abnormalities of other heart rate neither with cardiovas- nlm.nih.gov/books/NBK345/ cular abnormalities (12,13). 7. Van Oort A. The Vibratory Innocent Heart Murmor in School- children: Difference in Auscultatory Findings Between School 6. CONCLUSION Medical Officers and a Pediatric Cardiologist. Pediatric Car- The characteristics of accidental murmurs are that they diol. 1994; 5: 282-7. are purely systolic, maximally affecting up to 60% of the 8. Van Oort A. The Vibratory Innocent in School- systole, usually occur in early systole, are separated from children: A Case-Control Doppler Echocardiographic Study. both tons, with relatively shorter duration, with poor Pediatric Cardiol. 1994; 15: 275-81. propagation (where they occur and die), and are mainly 9. Kurtz KJ. and Hums of the Head and Neck. In: Walker of ejection (extrusion) type. Accidental heart murmurs HK, Hall WD, Hurst JW, editors. Clinical Methods: The His- are revealed by auscultation in over 50% of children and tory, Physical, and Laboratory Examinations. 3rd edition. Bos- youth, with a peak occurrence between 3-6 years or 8-12 ton: Butterworths; 1990. Chapter 18. Available from: https:// years of life. Reducing the frequency of murmurs in the www.ncbi.nlm.nih.gov/books/NBK289/ later period can be related to poor conduction of the 10. Gressner IH. What makes a heart murmur innocent? Pediatr murmur, although the disappearance of murmur in prin- Ann. 1997 Feb; 26(2): 82-4, 87-8, 90-1. ciple is not expected. It is the most common reason of 11. Shaver JA. Cardiac auscultation: A cost-effective diagnostic cardiac treatment of the child, and is a common cause of skill. Curr Probl Cardiol. 1995; 20: 441. unreasonable concern of parents. 12. Klewer SE, Donnerstein RL, Goldberg SJ. Still’s like innocent murmur can be produced by increasing aortic velocity to a • Conflict of interest: none declared. threshold value. Am J Cardiol. 1991; 68: 810-12. • Author*s Contribution: E.B. made substantial contribution to con- 13. Danford DA, Nasir A, Gumbiner. Cost assessement of the eval- ception and design (acquisition of data, analysis and interpretation uation of the heart murmurs in children. Pediatrics. 1993; 91: of data). Z.B. revised it critically and gave final approval of the version 65-368. to be submitted. 14. Keck EW. Pedijatrijska kardiologija. Školska knjiga, Zagreb, 1995; 1-15. REFERENCES: 15. McCrindle WB, Shaffer MK, Kan SJ, Zahka GK, Rowe AS, 1. Smith KM. The innocent heart murmur in children. J Pediatr Kidd L. Cardinal Clinical Signs in the Differentiation of Heart Health Care. 1997 Sep-Oct; 11(5): 207-14. Murmurs in Children.Arch Pediatr Adolesc Med. 1996; 150: 2. Wiles HB, Saul JP. Pediatric cardiac auscultation. J S C Med 169-74. Assoc. 1999 Oct; 95(10): 375-8. 16. Wiles HB, Saul JP. Pediatric cardiac auscultation J S C Med 3. Begic Z, Dinarevic SM, Pesto S, Begic E, Dobraca A, Masic Assoc. 1999 Oct; 95 (10): 375-8. I. Evaluation of Diagnostic Methods in the Differentiation of 17. Asprey DP. Evaluation of children with heart murmurs. Lip- Heart Murmurs in Children. Acta Inform Med. 2016; 24(2): pincotts Prim Care Pract. 1998 Sept-Oct; 2(5): 505-13. 94-8. 18. Marinović B, Anamneza i klinički pregled djeteta, Školska kn- 4. Alvares S, Ferreira M, Mota CR. Intial assessment of heart jiga, Zagreb, 1994; 19-35, 68-74. murmurs in children: role of complementary diagnostic tests. 19. Begic Z, Begic E, Begic N. Differential Diagnosis of Inno- Rev Port Cardiol. 1997 Jul-Aug; 16(7-8): 621-24. cent Heart Murmurs In Children. American Journal of Car- 5. Constant J. How to Differentiate Ejection Murmurs from Sys- diology. 2015; 115: S30. doi:http://dx.doi.org/10.1016/j.amj- tolic Regurgitant Murmurs. Keio J Med. 1995; 44(3): 85-7. card.2015.01.114.

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