1. Incidental Detection of cardiac murmurs
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GPSTP

2. 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%
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3. 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
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4. 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
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GPSTP

5. 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
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GPSTP

6. 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
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GPSTP

7. 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.
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8. 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
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GPSTP