Congenital heart disease diagnosed with echocardiogram in newborns with asymptomatic cardiac murmurs: a systematic review.

BACKGROUND: More than 50% of newborns with congenital heart disease (CHD) are unrecognized at birth; however, the use of echocardiogram (Echo) for diagnosing CHD in newborns with asymptomatic, non-syndromic cardiac murmurs (ANCM), has not been systematically reviewed yet. We aimed to identify the incidence of CHD diagnosed with Echo and systematically review whether Echo should be recommended in this patient group. METHODS: The methodology utilized in this systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Using the MEDLINE, EMBASE, Web of Science, and Cochrane Library databases, we performed a systematic review of publications reporting CHD diagnosed with Echo in newborns with cardiac murmurs. The quality of the included studies was evaluated using the Study Quality Assessment Tools developed by the National Institutes of Health. RESULTS: Of the 630 studies screened, six cohort studies, four cross-sectional studies, and two case reports were included in this review. The incidence of cardiac murmurs ranged from 0.6-8.6%. Among the 1928 newborns with ANCM, 719 (37.3%) were diagnosed with Echo as having CHD, and ventricular septal defect was the most common congenital malformation. More than 50% of the newborns showed moderate CHD necessitating outpatient cardiology follow-up, and 2.5% had severe CHD requiring immediate interventions, such as cardiac catheterization and heart surgery. CONCLUSIONS: In this systematic review, a high incidence of CHD in newborns with ANCM was detected using Echo. This indicates that the use of Echo for diagnosing CHD in healthy newborns with cardiac murmurs could be helpful in earlier detection of CHD, thereby improving clinical outcomes for newborns with severe CHD.

Cardiovascular images: vascular hamartoma of the mitral valve in a horse.

An 8-month-old Hanoverian gelding was presented with a history of cardiac murmurs that were not apparent as a foal nor reported at the time of castration. Major echocardiographic findings included mitral valvular thickening, functional stenosis, and mitral regurgitation of sufficient severity to cause diastolic and systolic cardiac murmurs, left-sided volume overload, and pulmonary hypertension. Due to the hemodynamic severity of the lesion and poor prognosis for future performance and longevity, euthanasia was elected. On gross postmortem examination, there was focal fibrous epicarditis affecting the heart base, and the left atrium was moderately dilated. The mitral valve surface was irregular and contained several nodules along the atrial face of the cusp. Histologically, this lesion was diagnosed as a vascular hamartoma, which is rarely reported in veterinary species and has not been described in heart valves. This benign proliferative lesion, and concurrent valvular dysfunction, was associated with an unusual manifestation of clinically evident disease and should be differentiated from common incidental valvular lesions such as hematocysts.

Unusual case of primary pulmonary Hodgkin's lymphoma presenting with a continuous murmur.

Systemic to pulmonary fistulas are an unusual entity, even more so in association with Hodgkin's lymphoma. We herein report a case of a 33-year-old woman that presented with an incidental lung lesion on a chest radiograph with an associated high-frequency continuous murmur over the lesion. The diagnosis of primary pulmonary Hodgkin's lymphoma, nodular sclerosis type, was obtained by a CT transthoracic biopsy. We achieved an excellent response after polychemotherapy with near-complete disappearance of the mass and a residual faint systolic murmur over the lesion.

Asymptomatic young man with an incidental murmur.

CLINICAL INTRODUCTION: A 32-year old man was referred to our institution for transthoracic echocardiography (TTE) following detection of an incidental murmur on physical examination before blood donation. He was asymptomatic with no significant medical history. Physical examination revealed dual heart sounds with a grade II/VI systolic murmur heard in the left sternal border. An ECG was in normal sinus rhythm. TTE was performed (figure 1A-C, online supplementary videos 1-4) followed by cardiac CT angiography (CTA) (figure 1D,E).heartjnl;104/15/1307/F1F1F1Figure 1(A) Transthoracic echocardiography, parasternal left ventricular long axis view. (B) Colour Doppler of modified short axis in the mid-left ventricular level. (C) Doppler flow velocity profile. (D) Cardiac CT angiography (CTA) sagittal reconstruction. (E) Three-dimensional CTA reconstruction of the heart. QUESTION: What is the diagnosis?Pericardial cyst.Ventricular septal defect.Kawasaki.Anomalous left coronary artery from pulmonary artery (ALCAPA).

Immature teratoma mimicking pulmonary stenosis: a case report.

BACKGROUND: Immature teratoma in a mediastinal location is a rare disease that might present as a valve pathology. Germ cell tumors with mediastinal locations account for up to 6% of immature teratoma cases. We present a case of an immature teratoma located primarily in the anterior mediastinum that manifested solely through symptoms of pulmonary stenosis. CASE PRESENTATION: We report a case of a 20-year-old white man with an immature teratoma who presented with progressive exertional dyspnea. During a cardiac examination, an ejection systolic murmur was observed, and echocardiography findings at an Emergency Centre revealed high velocity flow at the level of the pulmonary artery, indicating pulmonary stenosis. He was hospitalized in our Cardiology Department for further investigation. A chest X-ray revealed a mediastinal mass, and repeated echocardiography indicated the presence of a large mediastinal mass compressing his main pulmonary artery. Magnetic resonance imaging confirmed the tumor in the mediastinum, and a histopathological diagnosis of immature teratoma was established following biopsy. CONCLUSION: Immature teratoma causing cardiac-related complaints might shift the diagnosis toward cardiovascular diseases, thus requiring prompt examination by standard and sophisticated methods to clarify the diagnosis.

An incidental encounter of a rare high take-off right coronary artery: A case report.

RATIONALE: High take-off of the coronary arteries is a rare cardiac anatomic anomaly, which may occur independently or with other congenital heart defects. In the clinical setting, it is noteworthy as a cause of sudden cardiac death. Further, it is vital to identify such anomalies to avoid intraoperative catastrophes in surgeries for congenital heart defects. PATIENT CONCERNS: A II/6 systolic heart murmur on physical examination was incidentally found in a 9-year-old boy; he was confirmed to have a secundum-type atrial septal defect on echocardiography. He was referred to our institution for elective surgery. DIAGNOSES: The preoperative echocardiogram confirmed the presence of an atrial septal defect, and during the surgical procedure, a high take-off right coronary artery was found. INTERVENTIONS: The atrial septal defect was closed surgically, and care was taken to avoid clamping the anomalous right coronary artery when placing the aortic cross-clamp. OUTCOMES: Postoperative echocardiogram verified the presence of the high take-off right coronary artery and a satisfactory repair of the atrial septal defect. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. LESSONS: This case suggests that it is critical to perform echocardiography to assess the anatomy of the coronary arteries, especially in pediatric cardiac patients. In addition, multi-detector computed tomography may be considered if appropriate. Care should be taken to assess the coronary anatomy for anomalies during interventional therapy or surgery, especially in congenital cases.

The not so innocent heart murmur: a 5-year experience.

BACKGROUND: Auckland City Hospital (ACH) established a Heart Murmur Clinic (HMC) with the aim of providing prompt assessment of patients with asymptomatic systolic murmurs. This may lead to early intervention and improved outcomes if significant structural heart disease is detected and reassurance if no significant findings are found. Similar clinics for children have proven beneficial; the benefit of a HMC in an adult population has been difficult to determine. AIM: To review the clinical demographics and echocardiographic information of patients presenting to our HMC, to assess what proportion of significance structural heart disease had and determine the common structural abnormalities in this population. METHODS: This is a retrospective review of patients aged ≥15 years presenting to our HMC between March 2010 and December 2015 with an asymptomatic systolic murmur. Patients with previous cardiac surgery or known congenital or valvular heart disease were excluded. RESULTS: A total of 1221 patients was reviewed over the 5-year period; 980 underwent echocardiography. Significant cardiac disease was detected in 156 patients, with 23 patients requiring surgical intervention over the 5-year period. Significant aortic stenosis (n = 43) and mitral regurgitation (n = 48) were the most common pathologies. Patients > 65 years were more likely to have structural heart disease (16% vs 11%, P < 0.05). CONCLUSION: Establishing a HMC has allowed the screening of a large number of patients who would otherwise have low priority for assessment. We have identified a large proportion with significant structural disease, which has allowed for early surgical intervention when appropriate and may potentially result in improved patient outcomes.

Appropriate Use and Clinical Impact of Echocardiographic "Evaluation of Murmur" in Pediatric Patients.

OBJECTIVE: To determine the appropriateness and yield of transthoracic echocardiograms (TTE) for murmur evaluation based on the pediatric Appropriate Use Criteria (AUC) and study the influence of patient age and physician experience on TTE appropriateness, yield, and ordering frequency. DESIGN: Retrospective review of medical records of patients referred to our practice for murmur evaluation from April to September 2014. Data collected included indication for TTE, patient age, physician experience since fellowship, TTE findings and exit diagnosis. Appropriateness was assigned based on the AUC document. SETTING: Pediatric cardiology clinics affiliated with a large pediatric cardiology practice. PATIENTS: One thousand seven hundred one consecutive patients (≤ 18 years) referred to our practice for murmur evaluation. INTERVENTIONS: Not applicable OUTCOME MEASURES: The primary outcome was appropriateness of TTE orders. The secondary outcomes were the yield of abnormal TTE findings and the influence of patient age and physician experience on appropriateness, yield, and frequency of ordering TTEs. RESULTS: Of the 1701 patients referred for a murmur, 526 (30.9%) had a TTE [441/526 (83.8%) Appropriate; 85/526 (16.2%) Rarely Appropriate]. Abnormal findings were present in 130/441 rated Appropriate and none rated Rarely Appropriate. Infants <3 months had the highest rate of TTEs rated Appropriate and the highest yield of abnormal findings. Physicians with >20 years of experience not only had the lowest TTE ordering rate but also the lowest appropriateness rate with no difference in the yield of abnormal findings. CONCLUSIONS: Most TTEs ordered for murmur were for indications rated Appropriate. Abnormal findings were present in one-fourth and only those rated Appropriate. Patient age and physician experience can significantly influence TTE utilization. This information is helpful in designing quality initiatives to optimize TTE utilization for murmur evaluation.

Registry report of structural and functional cardiac abnormalities diagnosed by echocardiography in an asymptomatic population.

BACKGROUND: The epidemiology of heart disease is changing, with rheumatic heart disease becoming less common but degenerative valve disorders, heart failure and atrial fibrillation (AF) increasing. OBJECTIVE: We sought to determine the prevalence of structural cardiac abnormalities in the apparently symptom-free adult population within our prospective echocardiography (echo) registry. METHODS: Our echo registry comprised echo studies and associated demographic and clinical data obtained prospectively from 362 consecutive asymptomatic subjects aged 50-74 years and without known heart disease referred between 2011 and 2012 from general practices in the South East of England. RESULTS: 221 echo abnormalities were detected in 178 (49%) subjects (46% men; mean (±SD) age 63.9±9.2 years; 98% Caucasian). A major abnormality was detected in seven subjects: four had a large secundum atrial septal defect, one had critical aortic stenosis, one severe mitral regurgitation and one features of hypertrophic cardiomyopathy. Twelve subjects had left ventricular systolic dysfunction with an ejection fraction (EF) <50% (of whom 10 had EF <40%). Four subjects had AF. Minor echo abnormalities were evident in the remaining 171 (47%) subjects. Abnormalities were commoner in patients with cardiovascular risk factors or a history of cardiac disease than in those without (53% vs 38%). In multivariate analyses stratified by gender, for women, increased age (F=33.3, p<0.001) and systolic blood pressure (F=9.2, p=0.003) were associated with abnormal echo findings; for men, increased age (F=12.0, p<0.001) and lower cholesterol (F=4.2, p=0.042) predicted an increase in abnormal findings on echo. CONCLUSIONS: Unrecognised cardiac abnormalities are very common in middle-aged men and women with no overt symptoms. Echo offers the potential to identify the need for early intervention and treatment to improve cardiovascular outcomes.

A cardiac haemangioma: the contribution of myocardial contrast echocardiography in the diagnosis.

Cardiac haemangiomas are extremely rare and account for approximately 2% of all primary resected cardiac tumours. They can occur in any chamber and at any level, from pericardium to endocardium. Myocardial contrast echocardiography is an imaging tool for the assessment of myocardial microcirculation. It can also be used for the evaluation of the relative perfusion of a cardiac mass. We report a case of a 17-year-old male patient who was referred for cardiological evaluation because of a 2/6 systolic murmur. Transthoracic echocardiography revealed a mass in the left ventricle. Using myocardial perfusion contrast echocardiography, the mass was rapidly filled with contrast greater than the adjacent myocardium, suggesting intense vascularisation. The mass was successfully resected and the subsequent histopathological examination showed a cardiac haemangioma. Therefore, myocardial perfusion contrast echocardiography appears to be a valuable diagnostic tool in differentiating the different types of cardiac masses.

[Incidental finding of a cardiac paraganglioma]. / Zufallsbefund eines kardialen Paraganglioms.

Cardiac paragangliomas are extremely rare neoplasms with an incidence of 1% of all cardiac tumors and can be completely asymptomatic, therefore, diagnosis is difficult. This article reports the case of an 18-year-old man with a heart murmur detected during a routine physical examination. Echocardiography revealed a heart tumor measuring 7 cm in size in the right atrium. Due to the tumor size and the threat of tricuspid valve insufficiency, tumor resection was performed. The histopathological examination revealed a cardiac paraganglioma with positive reactions of the tumor cells for chromogranin A, synaptophysin and CD56. Differentiating a primary cardiac paraganglioma from other more common cardiac tumors and particularly from metastases of neuroendocrine neoplasms from other locations is essential not only for the further clinical treatment but also for the prognosis of the patient.

Características clínicas de los pacientes con soplos atendidos en una consulta de cardiopediatría / Clinical characteristics of patients with murmurs cared in a pediatric cardiology consultation

Fundamento: La auscultación de un soplo cardíaco durante el examen físico de un niño es frecuente, por lo que constituye el principal motivo de interconsulta en cardiología pediátrica. Objetivo: Identificar las características clínicas de los pacientes con soplos atendidos en una consulta de cardiopediatría. Metodología: Se estudiaron 118 niños durante el periodo de septiembre 2011 a diciembre 2012. Las variables utilizadas fueron edad, sexo, antecedentes patológicos familiares, síntomas asociados, localización del soplo, intensidad, complementarios (telecardiograma, electrocardiograma y ecocardiograma doppler). Resultados: Predominó el grupo de cero días a cinco años, y el sexo masculino. El dolor precordial, las palpitaciones y la disnea constituyeron los síntomas más frecuentes asociados al soplo. En 94 niños el soplo se ubicó en la región mesocárdica y en 106 fueron grado II. Conclusiones: La auscultación de un soplo cardíaco durante el examen físico de un niño es un hecho frecuente, por lo que constituye motivo de interconsulta periódicamente en la cardiología pediátrica.

Background: auscultation of a heart murmur during a physical examination of a child is common, which is the main interclinical reason in pediatric cardiology. Objective: To identify clinical characteristics of patients with murmurs cared in a pediatric cardiology consultation. Methodology: 118 children were studied from September 2011 to December 2012. The variables used were age, gender, family medical history, associated symptoms, location of the murmur, intensity, complementary exams (telecardiogram, electrocardiogram and echocardiogram doppler). Results: The group of 0 days to five years and male sex predominated. Chest pain, palpitations and dyspnea were the most common symptoms associated with the murmur. In 94 children the murmur was located in the mesocardiac region and 106 were grade II. Conclusions: Auscultation of a heart murmur during a physical examination of a child is frequent, that is why it is a periodically interclinical reason in pediatric cardiology consultation.

A 90-year-old patient presenting with postoperative hypotension and a new murmur: a case report.

INTRODUCTION: Hospitalists are frequently consulted on postoperative patients with hypotension. Postoperative hypotension is common and can be due to variety of causes. Systolic anterior motion of the mitral valve leading to left ventricular outflow tract obstruction is a rare cause of postoperative hypotension and can occur without prior structural heart disease. A high index of suspicion can lead to early recognition of this unique condition. CASE PRESENTATION: A 90-year-old Caucasian woman with no known structural heart abnormality was admitted to the intensive care unit with hypotension after a left hip arthroplasty revision. A transthoracic echocardiogram revealed systolic anterior motion of the mitral valve and dynamic left ventricular outflow tract obstruction as the likely cause of her hypotension. Our patient was treated with fluid resuscitation and phenylephrine with improvement in blood pressure. A repeat echocardiogram on postoperative day 5 showed resolution of the left ventricular outflow tract obstruction. Intraoperative vasodilatation and volume loss that caused underfilling of the left ventricle likely led to dynamic outflow tract obstruction in our patient. CONCLUSIONS: Hospitalists should be aware of systolic anterior motion of the mitral valve as a rare peri-operative complication in patients with or without underlying cardiac pathology as it is treated differently than other causes of peri-operative hypotension. Clinical suspicion, early recognition, and prompt treatment can improve clinical outcomes in these patients.

Murmur intensity in small-breed dogs with myxomatous mitral valve disease reflects disease severity.

OBJECTIVES: To determine whether murmur intensity in small-breed dogs with myxomatous mitral valve disease reflects clinical and echocardiographic disease severity. METHODS: Retrospective multi-investigator study. Records of adult dogs Ä20 kg with myxomatous mitral valve disease were examined. Murmur intensity and location were recorded and compared with echocardiographic variables and functional disease status. Murmur intensities in consecutive categories were compared for prevalences of congestive heart failure, pulmonary hypertension and cardiac remodelling. RESULTS: 578 dogs [107 with "soft" (30 Grade I/VI and 77 II/VI), 161 with "moderate" (Grade III/VI), 160 with "loud" (Grade IV/VI) and 150 with "thrilling" (Grade V/VI or VI/VI) murmurs] were studied. No dogs with soft murmurs had congestive heart failure, and 90% had no remodelling. However, 56% of dogs with "moderate", 29% of dogs with "loud" and 8% of dogs with "thrilling" murmurs and subclinical myxomatous mitral valve disease also had no remodelling. Probability of a dog having congestive heart failure or pulmonary hypertension increased with increasing murmur intensity. CLINICAL SIGNIFICANCE: A 4-level murmur grading scheme separated clinically meaningful outcomes in small-breed dogs with myxomatous mitral valve disease. Soft murmurs in small-breed dogs are strongly indicative of subclinical heart disease. Thrilling murmurs are associated with more severe disease. Other murmurs are less informative on an individual basis.