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Continuous Heart Murmur: a Sign of Inestimable Value

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Continuous Heart Murmur: a Sign of Inestimable Value CorSalud 2013 Jul-Sep;5(3):285-295 Cuban Society of Cardiology ________________________ Review Article Continuous heart murmur: a sign of inestimable value Dr. Hiram Tápanes Daumya, MD; Maylín Peña Fernándezb, MD; and Andrés Savío Benavidesa, MD a William Soler Pediatric Cardiology Hospital. Havana, Cuba. b Carlos J. Finlay Military Hospital. Havana, Cuba. Este artículo también está disponible en español ARTICLE INFORMATION ABSTRACT This literature review is conducted to clarify the pathophysiological, semiological and Received: 3 de diciembre de 2012 causal elements of a continuous murmur, and describes the fundamental clinical Accepted: 21 de febrero de 2013 elements of the different diseases that can cause these murmurs, and the criteria for its clinical, hemodynamic or surgical approaches. The semiological elements of a con- tinuous murmur are emphasized, which complemented with electrocardiogram and Competing interests telecardiogram allow us to reach a definite diagnosis with high accuracy, demons- The authors declare no competing interests trating that this is a sign of inestimable value to pediatric cardiologists. Palabras clave: Heart murmur, Congenital heart disease, Cardiology, Pediatrics Acronyms Soplo continuo: un signo de inestimable valor APW: aortopulmonary window PDA: patent ductus arteriosus RESUMEN Con el objetivo de precisar los elementos fisiopatológicos, semiológicos y causales de un soplo continuo se realiza esta revisión bibliográfica, donde se describen los ele- mentos clínicos fundamentales de las diferentes enfermedades capaces de provocar estos soplos, así como los criterios para su abordaje clínico, hemodinámico o quirúr- gico. Se enfatiza en los elementos semiológicos de un soplo continuo, que comple- mentados con el electrocardiograma y el telecardiograma nos permiten acercarnos con alta precisión al diagnóstico de certeza, lo que demuestra que este constituye un signo de inestimable valor para el cardiopediatra. On-Line Versions: Palabras clave: Soplo, Cardiopatía congénita, Cardiología, Pediatría Spanish - English INTRODUCTION Heart murmurs are commonly detected during routine physical examination H Tápanes Daumy in the pediatric population and are the most prevalent sign of cardiopedia- Cardiocentro Pediátrico William Soler trics1-3. Therefore, it is the leading cause of referral to pediatric cardiologists Ave 43 Nº 1418. Esquina Calle 18. 4 CP 11900. La Habana, Cuba at Boston Children's Hospital . E-mail address: The blood flow through the cardiovascular system is silent because the cu- [email protected] rrent is laminar as blood columns. Heart murmurs are the result of turbulence RNPS 2235-145 © 2009-2013 Cardiocentro Ernesto Che Guevara, Villa Clara, Cuba. All rights reserved. 285 Continuous heart murmur: a sign of inestimable value in the current flowing at high speed into or out of the Fogel’s pulmonary murmur, aortic innocent mur- heart, causing audible vibrations that reach frequen- mur, Still’s vibratory murmur and Evans’ late mur- cies between 20 and 20 thousand hertz5,6. mur8-11. Three key factors determine the production of tur- bulence (murmurs), they are: Other authors include these functional or innocent 1. Increasing flow through normal or abnormal valves murmurs in the systolic group, having in mind that in- in anterograde direction (normal direction). deed all these occupy the systolic phase of the cardiac 2. Forward flow through an irregular stenotic valve, or cycle. towards a dilated vessel (normal direction). In order to clarify the pathophysiological, causal 3. Backward flow through an insufficient valve or and semiological aspects of a continuous murmur congenital defect5. this literature review is conducted, which describes the fundamental clinical elements of the different In general and considering the moment of the car- diseases that can cause continuous murmurs, as well diac cycle in which murmurs appear, these can be as the criteria for clinical, hemodynamic or surgical classified into: approaches. • Systolic murmurs: They are divided into mesosysto- lic-ejective (aortic and pulmonary foci), and regur- gitant that are auscultated at the level of the mitral CAUSES FOR CONTINUOUS MURMUR and tricuspid atrioventricular valves; also those re- Continuous murmurs are those that persist and are lated to interventricular septation defects belong heard in systole and diastole, and are caused by the to this subgroup. continuous flow of blood from an area of high pres- • Diastolic murmurs: They are subdivided in regurgi- sure to one of low pressure, maintaining a pressure tant that are present in pulmonary and valvular gradient throughout the cardiac cycle8. aortic insufficiency cases, and those that relate to An essential element in the pathophysiology of the rapid ventricular filling (mid-diastolic murmurs) continuous murmur is the hemodynamic phenome- and presystolic atrial filling. non responsible for maintaining a pressure gradient • Continuous murmur: those auscultated in both between the vessels, and capable of maintaining a phases of the cardiac cycle and whose origin is re- turbulent flow which covers the systole and a segment presented by a long list of multiple causes. of cardiac diastole, and masks the second cardiac sound. In this general classification of heart murmurs some Some authors classify continuous murmurs accor- authors include: ding to the structures involved in the shunt and divide • Systolic-diastolic murmurs: They can also be aus- them into: arterio-arterial, arterio-venous and veno- cultated in both phases of the cardiac cycle but the venous12. second heart sound between them is defined, The classical semiological description of a conti- while in the continuous the second noise is masked nuous murmur was made by Gibson in 1900 in relation by the murmur. The origin of systolic-dialostic mur- to the murmur present in patent ductus arteriosus murs is derived from the overlapping of diseases (PDA), referring to this as a machinery murmur. How- such as ventricular septal defect with aortic insuffi- ever, the diseases that make the causal list of the ciency, pulmonary or double aortic injury, common continuous murmur are multiple and all of them are trunk with valvular insufficiency, among others7. especially relevant for the pediatric cardiologist. • Innocent murmurs: They have a frequency of 60- 85% in children between three and six years old, In general, the causes of continuous murmur are: and are characterized by their short duration, sys- 1. PDA. tolic phase onset, low intensity, low irradiation, 2. Aortopulmonary window (APW). intensity change with the position and enhance- 3. Ruptured aneurysm of sinus of Valsalva. ment with hyperdynamic circulatory changes. In 4. Classic or modified Blalock - Taussig shunt. these cases, telecardiogram and electrocardiogram 5. Coronary arteriovenous fistulas. are normal. Among the most common causes are 6. Truncus arteriosus. 286 CorSalud 2013 Jul-Sep;5(3):285-295 Tápanes Daumy H, et al. 7. Venous hum. Follow up of continuous murmur in this disease is 8. Mammary souffle. extremely important for the pediatric cardiologist since its absence, or the only presence of the diastolic All causes of continuous murmur except for the component, together with a pulmonary component of mammary souffle, appear in childhood, and are the second hyperphonetic sound should lead to sus- associated with congenital malformations or palliative pect the presence of pulmonary hypertension, which procedures related to these. in extreme circumstances leads to the Eisenmenger syndrome, that determines the impossibility of the definitive defect correction. Patent ductus arteriosus Diagnosis is complemented by the electrocardio- As the name suggests it is caused by postnatal per- gram that can vary over a spectrum that goes from sistence of the ductus arteriosus, which is an embryo- normal in small PDA to biventricular growth in that of logical structure originating from the distal left sixth large hemodynamics impact. When Eisenmenger syn- aortic arch and connects the pulmonary artery trunk, drome develops some signs of right ventricular hyper- near the left pulmonary artery branch, with the des- trophy appear with QRS axis to the right, tall R in V1 cending thoracic aorta of the left subclavian artery and V2 and right Sokoloff-Lyon signs (R of V1-V2 + S of after birth. The existence of the ductus arteriosus is V5-V6 greater than 11 millimeters). essential for intrauterine life, as 60% of the cardiac In telecardiogram some signs of left ventricular hy- output passes through it. pertrophy with a domed pulmonary artery trunk and The first accurate description of the ductus arte- increased pulmonary flow are observed, although in riosus was made by James Gibson in 1900, however, small PDA the telecardiogram can approximate the William Harvey had already made excellent anatomical normal. In Eisenmenger syndrome pulmonary oligo- descriptions in the sixteenth century7,12. hemia is associated with right ventricular growth. For its size and hemodynamic effects PDA is classi- Echocardiography confirms the diagnosis. fied as: Medical treatment is focused on the control of - Large: when it measures over six millimeters at heart failure with diuretics, aldosterone inhibitors, di- both ends (aortic and pulmonary). goxin, angiotensin converting enzyme inhibitors or an- - Moderate: when it measures three to six millime- giotensin II–receptor inhibitors. ters at both ends (aortic and pulmonary). Its definitive treatment, depending on the
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