Incidental Detection of cardiac murmurs 28/11/2018 GPSTP

Pre-Antenatal Scan Era ----------------------------------- Post Antenatal Scan Era I divide the last 20 years into pre-ante and post antenatal Evolving technique Doing since early 1990s Driver dependent and pick up rate is extremely variable. Pick up rate of CHD is between 25% to <85% 28/11/2018 GPSTP 2

Timing of Presentation Remember I mentioned about the classification of CHD based on severity Red column signifies the critical CHD. Quite a few are detected in the antenatal scans and appropriate management plans are made before delivery Some are delivered in tertiary centre Significant number of these are not picked in the antenatal scan and present in the neonatal period either in the post natal ward or after discharge. I will take about this later. As you can most of the critical, major CHD present in the first year of life. Once present later always minor ones These include small VSD, PS, ASD etc. Unlikely to cause any problems but anything with heart gives a lots of anxiety Occasional major ones present after infancy and early childhood. These are mostly Coarctation of aorta. Please check femoral 28/11/2018 GPSTP 3

Innocent Murmurs Term coined by William Evans in 1947 More than >50% of all children have innocent heart murmurs Common age: 3 to 6 years Thin chest wall in children More angulated great vessels in children More dynamic circulation in children 28/11/2018 GPSTP

Pathological murmurs All diastolic murmurs Can be associated with thrill Radiates All pansystolic murmurs Late systolic murmurs Loud murmurs > 3/6 Continuous murmurs (except venous hum) Associated cardiac abnormalities 28/11/2018 GPSTP

Innocent Heart Murmurs Still’s murmur: Origin: Left Ventricular outflow Heard best left parasternal and aortic area systolic ejection murmur, vibratory, musical in quality. Seen in infancy to adolescence DD: VSD, Aortic stenosis, Pulmonary stenosis Best heard in Supine Pulmonary Flow Murmur Second most common. Hear best at the left mid to upper sternal border. Commonly heard when child is unwell No radiation DD: PS, ASD 28/11/2018 GPSTP

Innocent Heart Murmurs Supraclavicular arterial bruit: Above the right clavicle. Brachiocephalic arteries branching Neonatal peripheral pulmonary stenosis (PPS): Birth to 3-6 months. Heard best at base of the heart, both axillae and the back. Due to relative small size of branch pulmonary arteries and the angle of bifurcation of the Pas DD: PS, ASD Cervical venous hum; Continuous hum. Heard in the right infraclavicular area Better in sitting, disappear in supine and when pressure is applied to neck to reduce venous blood return. 28/11/2018 GPSTP

Management Don’t diagnose innocent heart murmurs in infancy! Check Saturations ≥99% Review the child later well Ensure that child is asymptomatic CXR/ECG rarely useful Echocardiogram: Gold standard 28/11/2018 GPSTP