W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page i Understanding Pediatric Heart Sounds W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page ii W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page iii Understanding Pediatric Heart Sounds second edition Steven Lehrer, MD The Mount Sinai School of Medicine New York, New York Saunders An Imprint of Elsevier Science Philadelphia London New York St. Louis Sydney Toronto W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page iv SAUNDERS An Imprint of Elsevier Science 11830 Westline Industrial Drive St. Louis, Missouri 63146 Understanding Pediatric Heart Sounds ISBN 1468138030 Copyright © 2003, Elsevier Science (USA). All rights reserved. 9781468138030 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the publisher. NOTICE Health care is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the licensed health care provider, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any injury and/or damage to persons or property arising from this publication. Previous edition copyrighted 1992 Library of Congress Cataloging-in-Publication Data Lehrer, Steven. Understanding pediatric heart sounds / Steven Lehrer.—2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 0-7216-9646-5 1. Pediatric cardiology—Diagnosis. 2. Heart—Sounds. I. Title. [DNLM: 1. Heart Valve Diseases—Child. 2. Heart Valve Diseases—Infant. 3. Heart Auscultation—Child. 4. Heart Auscultation—Infant. 5. Heart Sounds—Child. 6. Heart Sounds—Infant. WG 260 L524u 2003] RJ423 .L44 2003 618.92¢1207544—dc21 2002026834 Vice President and Publishing Director: Sally Schrefer Acquisitions Editor: Loren Wilson Developmental Editor: Nancy L. O’Brien Publishing Services Manager: John Rogers Project Manager: Doug Turner Designer: Kathi Gosche Cover Art: Kathi Gosche RT/MVY Printed in the United States of America. Last digit is the print number: 9 8 7 6 5 4 3 2 1 W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page v Preface In 1896, Dr. Thomas Morgan Rotch, Professor of Diseases of Children at Harvard Medical School, published a textbook of pediatrics. As Dr. Alexander Nadas noted, only seven of 1100 pages dealt with congenital disease of the heart. “It is usually possible to make a diagnosis of congenital heart disease,” wrote Dr. Rotch, but “a diagnosis of the especial lesion is, as a rule, impossible.” Indeed, the precise diagnosis was only of academic interest, because so little could be done for the patient. Dr. Rotch did mention that “the administration of digitalis in small doses with the utmost caution” was sometimes useful, but treatment was “essentially hygienic and symptomatic.” Another Harvard pediatrician, Professor John Lovett Morse, wrote a new pediatrics textbook in 1926. Morse devoted 40 pages to heart disease, of which less than five dealt with congenital abnormalities. Even the development of the x-ray had little impact on the diagnosis and treatment of congenital heart disease. “The Roentgen ray, which theoretically ought to be of considerable assistance in the diagnosis of special lesions, is practically of little assistance even in the hands of an expert,” wrote Dr. Morse. “Fortunately the diagnosis of the exact lesion is not of great importance in either prognosis or treatment. There is no curative treatment [and] nothing which will either diminish the defor mities or favor the closure of abnormal openings. The treatment must, there fore, be hygienic and symptomatic.” The Blalock-Taussig shunt operation and the subsequent develop ment of cardiovascular surgery revolutionized the treatment of heart disease in children. Heart deformities and abnormal openings could frequently be repaired, though precise diagnosis was a problem. The only certain diagnostic method was cardiac catheterization, an invasive tech nique. However, a physician skilled with a stethoscope could often make a correct diagnosis at the bedside. In the last decade, the perfection of echocardiography, Doppler ultra - sonography, and magnetic resonance imaging has made possible the accurate diagnosis of many structural heart abnormalities by non invasive methods. As a result, very few students receive the detailed instruction in the use of a stethoscope that would allow them to diagnose most pediatric heart problems. v W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page vi vi Preface Not all children are examined in a hospital setting. A stethoscope is still the best diagnostic tool when a child is examined at home, in school, or for the first time in the clinic. This book provides the information a caregiver needs to become proficient at pediatric cardiac auscultation. Steven Lehrer New York City W9646-Front matterISBN_W9646-Front matter.qxd 12/27/2011 7:24 PM Page vii Acknowledgments I wish to thank the following colleagues for their assistance: Dr. Eva Botstein Griepp, who reviewed both the manuscript and the audio CD; Dr. Jerome Liebman and Dr. C. K. Lowe, who reviewed the manuscript; Ms. Katherine Pitcoff, who edited the manuscript; and Mr. Mark Warner, who helped to make the audio CD. S1, S2, systolic ejection sound, midsystolic click, murmurs of mitral regurgitation, tricuspid regurgitation, aortic stenosis, aortic regurgi tation, patent ductus arteriosus, atrial septal defect, and whoop are from Physical Examination of the Heart and Circulation, Cardiac Auscultation (1984), by Joseph K. Perloff and Mark E. Silverman and are reproduced by kind permission of the American College of Cardiology. Still’s murmur, cervical venous hum, and murmur of ventricular septal defect are from The Guide to Heart Sounds: Normal and Abnormal (1988), by Donald W. Novey, Marcia Pencak, and John M. Stang. These sounds were produced by the Cardionics Heart Sound Simulator, Cardionics, Inc., Houston, Texas. They are reproduced by kind permission of Dr. Novey, Mr. Keith Johnson of Cardionics, and CRC Press, Inc., Boca Raton, Florida. S3, S4, quadruple rhythm, and summation gallop are from Under - standing Heart Sounds and Murmurs, 3rd edition (2001), by Ara G. Tilkian and Mary Boudreau Conover, WB Saunders Company, Philadelphia, and were also produced on the Cardionics Heart Sound Simulator, Cardionics, Inc., Houston, Texas. First pericardial friction rub was lent by Dr. W. Proctor Harvey. Second pericardial friction rub is from Essentials of Bedside Cardiology (1988), by Jules Constant, Little Brown, Boston, and is reproduced by kind permission of Dr. Constant and the publisher. Murmur of Blalock-Taussig shunt was produced with the Heart Sounds Tutor, Wolff Industries, San Marino, California, and is reproduced by permission. vii W9646-Table of contents_W9646-Table of contents.qxd 12/27/2011 6:13 PM Page viii W9646-Table of contents_W9646-Table of contents.qxd 12/27/2011 6:13 PM Page ix Contents Chapter 1 The Heart as a Pump 1 The Cardiac Cycle 1 Electrical Events in the Cardiac Cycle 1 Mechanical Events in the Cardiac Cycle 2 Ventricular Function 5 Diastolic Ventricular Filling 5 Systolic Ventricular Emptying 5 The Frank-Starling Law 6 The Cardiac Valves and Papillary Muscles 6 The Aortic Pressure Curve 10 Heart Sounds and Heart Function 10 Circulatory Changes at Birth 11 Communications Between Systemic and Pulmonary Circulations 14 Heart Failure 14 Chapter 2 Sound, Hearing, and the Stethoscope 17 Nature of Sound 17 Hearing 19 The Stethoscope 21 Chapter 3 History and Physical Examination of the Child With Heart Disease 27 History 27 Chief Complaint 27 Prenatal History 28 Birth and Past Health History 29 Family History 34 Physical Examination 34 Inspection 39 Palpation 45 Blood Pressure Determination 54 Additional Diagnostic Methods 59 Oximetry 59 ix W9646-Table of contents_W9646-Table of contents.qxd 12/27/2011 6:13 PM Page x x Contents Chest X-ray Studies 59 Two-Dimensional Echocardiography 59 Fetal Echocardiography 60 Doppler Studies 60 Cardiac Catheterization and Angiocardiography 60 Chapter 4 Phonocardiography and the Recording of External Pulses 63 Phonocardiography 63 Electrocardiography 64 Carotid Pulse Tracing 64 Jugular Pulse Tracing 67 Apexcardiography 67 Chapter 5 Auscultation Areas 71 Traditional Areas to Auscultate 71 Revised Areas to Auscultate 71 Left Ventricular Area 73 Right Ventricular Area 73 Left Atrial Area 74 Right Atrial Area 74 Aortic Area 75 Pulmonary Area 76 Back and Head 77 Where Should One Listen? 78 Maneuvers That Aid Cardiac Auscultation 78 Chapter 6 The First Heart Sound (S1) 81 The Origin of S1 81 The Nature of S1 81 Listening for S1 81 Splitting of S1 83 Normal Splitting of S1 83 Wide Splitting of S1 83 Intensity of S1 83 Extracardiac Factors Affecting S1 Intensity 84 Cardiac Factors Affecting S1 Intensity 84 Pathologic Conditions Affecting S1 Intensity 85 Beat-to-Beat Variations of S1 85 W9646-Table of contents_W9646-Table