Murmurs and the Cardiac Physical Exam

Carolyn A. Altman Texas Children’s Hospital Advanced Practice Provider Conference Houston, TX April 6 , 2018 The Cardiac Physical Exam

Before applying a stethoscope…..

Some pearls on • General appearance • Physical exam beyond the

2 Jugular Venous Distention Pallor

Cyanosis 3 Work of Breathing Normal infant breathing

Quiet Tachypnea

Increased Rate, Work of Breathing

4 Beyond the Chest

Clubbing

Observed in children older than 6 mos with chronic cyanosis

Loss of the normal angle of the nail plate with the axis of the finger

Abnormal sponginess of the base of the nail bed

Increasing convexity of the nail

Etiology: ? sludging

5 Chest

❖ Chest wall development and symmetry

❖ Long standing cardiomegaly can lead to hemihypertrophy and flared rib edge: Harrison’s groove or sulcus

6 Ready to Examine the Heart

Palpation

Auscultation

General overview

Defects

Innocent versus pathologic

7 Cardiac Palpation

❖ Consistent approach: palm of your hand, hypothenar eminence, or finger tips

❖ Precordium, suprasternal notch

❖ PMI?

❖ RV impulse?

❖ Thrills?

❖ ?

8 Cardiac

Where to listen:

★ 4 main positions ★ Inching

★ Ancillary sites: don’t forget the head in infants

9 Cardiac Auscultation

Focus separately on

v Heart sounds:

• S2 normal splitting and intensity?

• Abnormal sounds? Clicks, gallops

v Murmurs

v Rubs 10 Cardiac Auscultation

Etiology of heart sounds:

Aortic and pulmonic valves actually close silently

Heart sounds reflect vibrations of the cardiac structures after valve closure

Sudden deceleration of retrograde flow of the column of blood in the aorta and pulmonary when the elastic limits of the tensed valve leaflets are met

11 Cardiac Auscultation

S2 ❖ Physiologic splitting of S2: Increased systemic venous return and increased pulmonary capacitance during inspiration causes delayed closure of the ❖ S2 cannot be considered “normal” unless physiologic splitting is heard

12 S2: normal splitting Single S2: Pulmonar Hypertension

Wide, fixed splitting: ASD Paradoxical Splitting of S2: LBBB, severe LVOTO

13 S2 HInts

❖ If splitting persists while patient supine, try sitting position- less volume in heart may normalize splitting

❖ Listen for splitting at mid to ULSB in kids

❖ Infants: Mid to LLSB ❖ Splitting of S2 if the HR is over 160 hard to hear: gently blowing a breath in the baby’s face will slow HR

14 Cardiac Auscultation: S1

❖ Physiologic splitting of S1:

❖ Can be heard in children with slower heart rates.

❖ Varies with respiration as does S2

❖ Soft S1: low cardiac output,

❖ Loud S1: hyperdynamic (fever, exercise), mitral stenosis

15 Cardiac Auscultation

Gallops: S3 or S4

❖ Short, low pitched diastolic sounds

❖ Abnormal ventricular function

16 Auscultation: S3 Gallop

❖ Mid way thru diastole

❖ Muscle tensing at end of rapid, early filling which occurs with ventricular relaxation

❖ Later than split S2

❖ Earlier than S4

17 Auscultation: S4 Gallop

❖ If impaired ventricular relaxation, less filling of the ventricles during during early diastole and more during atrial contraction

❖ Hypertrophic cardimyopathy, eg

❖ S4 is thus a sound generated late in diastole

❖ Very close to S1, can mistake for split S1 or S1- ejection click

18 S1-Ej click S4 S3 and S4 Gallops

❖ Heard best with bell since low S3 pitched ❖ Can extinguish the sound by pressing too hard (turning bell into diaphragm) S4 ❖ Usually heard over mitral area, if LV dysfunction S1-Ej click ❖ Listen in left lateral decubitus position too ❖ If RV dysfunction-may hear best at LLSB 19 Other Extra Heart Sounds

❖ Ejection Click: opening of the aortic or pulmonary valve

❖ Mid-systolic click: MVP

❖ Opening snap of MS

❖ Listen for difference in timing, cadence

20 How to Characterize Murmurs

❖ Timing

❖ Site of maximum intensity

❖ Intensity

❖ Radiation

❖ Pitch:

❖ Associated findings: clicks, rumbles, precordial activity

❖ Different from previous in your patient

❖ Innocent or pathologic

21 Timing of Murmurs

Systolic ? Diastolic? or Continuous ?

❖ Systolic occurs as the heart contracts

❖ Diastolic as the heart relaxes

❖ continue from systole into diastole

❖ Find S2 and listen to whether the murmur comes before it, after it, or through it

❖ Inching the stethoscope can help with timing 22 Murmurs: Timing

Systolic murmurs:

❖ Regurgitant murmurs: Begin with S1

❖ Ejection murmurs: Begins shortly after S1

❖ Mid-systolic: MVP

23 Regurgitant Systolic Murmurs

❖MR, TR, VSD

❖Begin with S1: “coincident with S1”

❖Often holosystolic

24 Systolic Ejection Murmurs

❖ AS/PS, Still’s, pulmonary flow

❖ Begin after valve opens, so hear S1 then murmur

❖ Should be able to hear S2 distinctly

❖ Early systolic ejection click if semilunar valve stenosis

25 Mid Systolic Murmurs

❖Mitral valve prolapse

❖Click ushers in murmur

26 Diastolic murmurs

Aortic or pulmonary regurgitation: ❖High pitched ❖Decrescendo

27 Diastolic murmurs

Diastolic rumbles:

❖ Increased volume across MV or TV

❖ Low pitched filling noise

❖ Absence of silence

28 Continuous Murmurs

❖ Start during systole, continue past S2 Venous Hum ❖ Louder in systole: PDA, AVM, shunts

❖ Louder in diastole: venous hums, coronary fistula

PDA Coronary fistula AVM 29 Murmurs by location of greatest intensity:

Helpful in figuring out what is generating the murmur ❖ URSB: ❖ ULSB: Pulmonary stenosis, pulmonary flow, ASD ❖ LLSB: VSD, Still’s, TR ❖ Apical: Mitral 30 Characterize Murmurs:

Grading system allows accurate communication between caretakers ❖ Grade I: is there something there? ❖ Grade II: Ok, I can hear it ❖ Grade III: Boy, that’s loud ❖ Grade IV: Associated with a thrill, knock your socks off loud ❖ Grade V: Audible with scope off chest ❖ Grade VI: Audible without stethoscope

31 Characterize Murmurs:

Important to follow trends: ❖ Is an aorto-pulmonary shunt murmur getting softer? A shunt may be getting obstructed, outgrown, or PVR elevated ❖ Is the outflow tract obstruction getting worse in a patient with new ? ❖ Is the patient with TOF spelling or just colicky: the outflow murmur will get softer during a spell as less flow traverses the RVOT

32 Characterize Murmurs by Pitch:

❖ High

❖ Low

❖ Harsh (multitonal)

33 Congenital Heart Defects

❖ ❖ Patent Ductus Arteriosus ❖ Ventricular Septal Defect ❖ Pulmonary Stenosis ❖ Aortic Stenosis

34 CHD: Atrial Septal Defect

❖ Anatomy: described by location in the septum Secundum Primum Coronary Sinus Sinus Venosus ❖ Physiology and physical signs the same, regardless of location of ASD

35 CHD: Atrial Septal Defect

Physiology: Amount of shunting depends on v Size of defect v Differences in compliance between RV and LV- flow is usually left to right

36 CHD: Atrial Septal Defect

Palpation: right ventricular impulse from increased RV volume

37 CHD: Atrial Septal Defect

❖ Widely split S2: v Persistent separation of A2P2 components of S2 throughout respiratory cycle v Increased pulmonary capacitance or v Reciprocal changes in flow into the right atrium from the defect or systemic

38 CHD: Atrial Septal Defect

❖ Pulmonary flow murmur: v Large volume of blood crossing the pulmonary valve v ULSB to back v Ejection v Medium pitched

39 CHD: Atrial Septal Defect

Diastolic Rumble: Consistent with at least 2:1 Qp:Qs Low pitched Listen with bell at LLSB

40 CHD: Patent Ductus Arteriosus

Physiology: v In the setting of low pulmonary , flow is continuous, left to right v If large PDA, PA pressures may be high: flow can be •Left to right •Bidirectional •All right to left

41 CHD: Patent Ductus Arteriosus

Palpation ❖ RV impulse if pulmonary hypertension ❖ Hyperactive LV impulse if large volume of flow PDA

42 CHD: PDA Murmur

v Continuous if low pulmonary vascular resistance v Machinery like v Accentuated at end systole v Left infra-clavicular area, back, and left supraclavicular areas

43 CHD: Ventricular Septal Defect

Anatomy described by location Perimembranous Inlet Muscular Doubly committed- juxtarterial

44 CHD: VSD

Physiology: amount of shunting depends on ❖ Size of defect ❖ Pulmonary resistance: more shunting with decreasing resistance

45 CHD: VSD

Palpation: ❖ Quiet precordium? ❖ RV impulse may be present with volume or pressure loading ❖ +/- thrill: cannot determine size by presence of thrill

46 CHD: VSD

S2 in VSDs can be ❖ Normally split (typical) ❖ Widely split if very generous amount of flow crossing to fill RV ❖ Single: if pulmonary hypertension with elevated resistance

47 CHD: VSD Auscultation

Murmur ❖ Usually along LSB ❖ Very small defects do not radiate ❖ Subpulmonary VSDs follow the RV outflow to the pulmonary ❖ “Blowing” quality ❖ Start with S1

48 CHD: VSD murmurs

Holosystolic murmur: ❖ Starts with S1 (obscured) ❖ Ends with P2, S2 split normally ❖ Plateau shape ❖ The smaller the defect, the more high pitched

49 CHD: VSD murmur

Short systolic murmur consistent with very small defect v Starts with S1 v Ends before S2, as defect closed by ventricular contraction v Usually very localized, may only hear in certain positions

50 CHD: VSD

Mitral Rumble vIndicates at least 2:1 Qp:Qs vLow pitched vUse bell at apex

51 CHD: VSD

Diastolic rumble Can be quite subtle Listen for absence of diastolic silence Compare right and le chest

52 CHD: VSD

Very Large VSDs vAllow high pressure and high flow v If le unrepaired: elevated PVR develops, eventually Eisenmenger syndrome Palpaon v RV impulse v Palpable S2

53 CHD: VSD

Large VSDs: Systolic Murmur vCan be holosystolic, if any pressure restricon v If no pressure restricon, may be no murmur, or a pulmonary oulow murmur

54 CHD: VSD

Eisenmenger’s v S2 loud and single v Pulmonary valve click: dilated pulmonary root v Graham-Steele murmur: pulmonary insufficiency

55 CHD: Tetralogy of Fallot Physiology: v Balance between VSD flow and pulmonary valve and sub valve stenosis v “Pink” tets have little pulmonary stenosis v Other extreme: pulmonary atresia with VSD v PS typically progresses over time

56 CHD: TOF

Palpaon: v RV impulse v Possible thrill

57 CHD: TOF

Systolic Murmur: reflects PS, not VSD v MLSB to ULSB to back v Starts with S1, given subvalvar component v As subps worsens, murmur decreases in intensity: pop-off through VSD to systemic circulaon v Listen for murmur to decrease in hypercyanoc spell

58 CHD: TOF

❖ Systolic Murmur: reflects PS, not VSD

59 CHD: TOF post repair

To and fro murmur ❖ PS/PI ❖ The murmur does not carry through S2-not continuous, not the diastolic component ❖ The diastolic murmur is of a different pitch

60 CHD: Pulmonary Valve Stenosis

❖ Anatomy: thickened, possibly dysplasc valve with limited systolic excursion ❖ Physiology: usually slowly progressive obstrucon

61 CHD: Pulmonary Valve Stenosis

Palpaon: v RV impulse: more than mild obstrucon v Thrill indicates more severe obstrucon

62 CHD: Pulmonary Valve Stenosis

Systolic Ejecon Click: v Either at ULSB, or upstream from valve at LLSB v Increases in intensity with expiraon v Moves closer to S1 with increasing PS

63 CHD: Pulmonary Valve Stenosis

Systolic Murmur: v Louder, longer, and later peaking with increasing stenosis v ULSB radiang to back, axilla

64 CHD: Stenosis

Anatomy: Thickened valve with decreased excursion Oen bicommissural Physiology: Obstrucon can be rapidly progressive, parcularly in infants Exercise increases the relave stenosis 65 CHD: Aortic Valve Stenosis

Palpaon: v Increased LV impulse with significant obstrucon v Thrills frequently presents vDo NOT reflect severity vCan be along LVOT, ULSB, carods, suprasternal notch

66 CHD: Aortic Valve Stenosis

Ejecon click: vOpening of non-compliant valve v Moves earlier in systole with increasing severity of obstrucon, may become inaudible v Heard at apex (upstream) or URSB (downstream)

67 CHD: Aortic Valve Stenosis

Murmur: v With increasing stenosis and normal cardiac output, murmur becomes louder, longer, later peaking vMay not have significant murmur if poor funcon (neonatal AS) v Heard at apex (upstream) or URSB (downstream)

68 Innocent Murmurs:

❖ Learn to recognize the three most common innocent murmurs of childhood: ❖ Venous hums, ❖ Still’s murmurs ❖ Physiologic pulmonary branch stenosis in infancy

❖ Anything else is not likely to be normal!

69 Innocent Murmurs: Still’s

Sll’s: most common innocent murmur ❖ I-III/VI SEM ❖ Soer with standing or sing ❖ Vibratory, twanging ❖ Low pitched, best heard with bell

70 Still’s murmur versus subaortic stenosis

Subaortic stenosis can mimic Still’s: both can be musical

71 Still’s murmur versus Subaortic Stenosis

❖ Use positional changes to help distinguish subAS from Still’s

❖ Dynamic obstruction in HCM accentuated with decrease in filling: murmur gets louder with stand

❖ Discrete sub AS will not usually get louder, but will also not diminish with stand

72 Innocent Murmur: Venous Hum

Venous Hum: innocent continuous murmur

❖ Turbulent flow merging from internal jugular and subclavian veins into SVC

❖ Louder in diastole

❖ Disappear when patient lies supine or turns head

❖ Audible along infraclavicular area, and low anterior neck (not the head)

❖ I-III/VI

73 Innocent Murmur: Venous Hum

Continuous murmur: whining, roaring, whirring, waterfall

74 Venous Hum versus Pathologic Continuous Murmurs

❖ PDA

❖ Coronary fistula

❖ Cranial AVM

❖ AO-PA shunt

75 Innocent Murmur: Peripheral Pulmonary Stenosis

❖ PPS in infant under 6 mos: same pitch as respirations

❖ As loud or loudest in back or axilla

❖ Systolic, high pitched, blowing

❖ Relatively small branch Pas arising at acute angle from large MPA

76 PPS versus Pathologic Murmurs

PPS-distinguish from

❖ Tiny VSD: better heard at mid to LLSB, not back/axilla

❖ PS: has a click

❖ ASD: Has abnl S2

77 Position Changes

❖ Distinguish innocent Still’s murmurs from LVOTO ❖ Detect gallops: apex, left lateral decubitus ❖ Distinguish venous hums from non-innocent continuous murmurs ❖ Mitral valve prolapse

78 Mitral Valve Prolapse

79 Auscultation

Artificial valves: should be audible without a stethoscope

★ Artificial aortic valves should have a mechanical S2

★ Artificial mitral valves should have a mechanical S1

★ Worry if it goes away-valve thrombosis

80 Tips for better exams

❖ Quiet room ❖ Recognize that naptime, stranger anxiety, hunger can adversely affect the situation ❖ Make the child as comfortable as possible: ❖ Silent distracters to entertain the child-flashlight, ID badge, toys, siblings

81 Tips for Better Exams

★ Tiny bodies: Use the right size stethoscope to minimize ambient noise and to accurately determine the presence and location of a murmur ★ Change the order of the exam to fit the child ★ Warm hands and scopes

82 ★ Remember- ★ Always not normal: RV impulse, thrills, apical murmurs, murmurs that increase with sitting or standing, murmurs with extra heart sounds, diastolic murmurs ★ Need to have a normally split S2 to be normal

★ If it does not sound innocent- needs further evaluation ★ Thank you.

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