Cardiac murmurs in children.

BACKGROUND: Approximately 50% of children experience a cardiac murmur at some point in their lives; <1% of these murmurs are attributed to congenital heart disease (CHD). Cardiac murmur might be the first clinical sign of a significant CHD in children. Despite careful routine medical examinations at birth, approximately 50% of CHD cases could remain unrecognised. OBJECTIVE: Cardiovascular symptoms and signs could be specific or non-specific in neonates and children with heart murmurs. Knowledge about red flags in history and physical examinations, and syndromic associations of common CHDs are important. Auscultatory skills to identify systolic, diastolic and continuous murmurs and heart sounds are essential. Differential diagnosis should be formulated based on the location of maximum intensity of murmurs. Younger infants and children with pathological murmurs and red-flag signs should be promptly referred to local paediatric cardiology services for further investigations. DISCUSSION: Significant skill and knowledge are required for the identification of critical murmurs and associated cardiovascular problems. This review provides a simplified comprehensive update on cardiac murmurs and associated conditions in neonates and children.

[Diagnosis and treatment of feline persistent ductus arteriosus: a retrospective evaluation of 17 cats]. / Diagnose und Therapie eines persistierenden Ductus arteriosus: Eine retrospektive Evaluation bei 17 Katzen.

OBJECTIVE: The objective of this study was to evaluate the signalement, clinical features, and echocardiographic findings of cats diagnosed with patent ductus arteriosus (PDA) as well as short- and medium-term outcome after successful ligation of the PDA. MATERIAL AND METHODS: Over a 10-year period 17 cats were diagnosed with PDA by transthoracic echocardiography. Thirteen cats were surgically treated by thoracotomy and ligation of the PDA. RESULTS: In all cats, a heart murmur was detected. In 88.2% of the cases, this presented as grade 4 out of 6 murmur (15/17 cats). A continuous murmur was more common (10/17 cats; 58.9%) than a systolic murmur (7/17 cats; 41.1%). Echocardiography showed that left ventricular internal diameter end diastole (LVIDd) and left ventricular internal diameter end systole (LVIDs) were significantly above reference values in the majority of cats. Mean diameter of the PDA measured at the widest point of the vessel was 3.4 mm (± 1.08 mm) and mean maximum flow velocity amounted to 5,06 m/sec (2,6m/sec-6,4m/sec). Surgery was successfully performed in all cats treated by surgical ligation and all of these patients were discharged after postoperative inpatient therapy. One cat experienced perioperative bleeding from the PDA, which was stopped efficaciously. This cat exhibited a residual shunt directly postoperatively; this could no longer be visualized in a re-check echocardiography 3 months later. Six cats were followed over a longer period of time. CONCLUSIONS: The surgical prognosis in this case study is very good with a postoperative survival rate of 100%. CLINICAL RELEVANCE: Surgical treatment of PDA is curative in animals not displaying advanced cardiac lesions. The auscultation of a heart murmur can provide initial findings indicative of PDA. Therefore, cardiac auscultation is warranted at every first presentation of a kitten. It must however be taken into consideration that not every cat with PDA necessarily has a continuous murmur but may display a systolic heart murmur. Therefore, it is important give utmost attention to the patients' clinical signs.

Spontaneous rupture of the right aortic sinus resulting in a sterile aorto-atrial fistula in a pet rabbit (Oryctolagus cuniculus).

Aortocardiac fistula is a broad term used to describe defects between the aorta and other cardiac chambers that can occur in humans and animals. A 1.5-year-old, 1.7 kg, male castrated Holland lop rabbit (Oryctolagus cuniculus) was presented for a two-week history of a heart murmur with corresponding cardiomegaly on radiographs. Physical examination confirmed a grade-V/VI continuous heart murmur on the right sternal border with a regular rhythm and a gallop sound. Echocardiography revealed an aortic-to-right-atrial fistula causing severe left-sided volume overload. Based on the echocardiographic findings, rupture of the right aortic sinus was suspected. Due to the poor prognosis, euthanasia was elected. On necropsy, a fistula was found connecting the right aortic sinus with the right atrium, without evidence of an inflammatory response nor evidence of an infectious etiology. The sudden onset of a heart murmur supported acquired fistulation from a ruptured aortic sinus (also known as the sinus of Valsalva), though a congenital malformation could not be completely excluded.

A Rare Cause of a Continuous Murmur in a Newborn.

We describe what we believe to be the first reported case of a neonate with right coronary ostial atresia with the right coronary artery originating from the left circumflex coronary artery, in conjunction with a right coronary artery to right ventricle fistula in a patient with otherwise normal cardiac anatomy. This was found following an evaluation for a continuous murmur at 2 weeks of life with elevated troponin and abnormal electrocardiogram. Thus far the child has required no intervention and is asymptomatic at 17 months of age, but he will require long-term follow-up to monitor the size of the fistula and potential for myocardial insufficiency.

Identification of Congenital Valvular Murmurs in Young Patients Using Deep Learning-Based Attention Transformers and Phonocardiograms.

One in every four newborns suffers from congenital heart disease (CHD) that causes defects in the heart structure. The current gold-standard assessment technique, echocardiography, causes delays in the diagnosis owing to the need for experts who vary markedly in their ability to detect and interpret pathological patterns. Moreover, echo is still causing cost difficulties for low- and middle-income countries. Here, we developed a deep learning-based attention transformer model to automate the detection of heart murmurs caused by CHD at an early stage of life using cost-effective and widely available phonocardiography (PCG). PCG recordings were obtained from 942 young patients at four major auscultation locations, including the aortic valve (AV), mitral valve (MV), pulmonary valve (PV), and tricuspid valve (TV), and they were annotated by experts as absent, present, or unknown murmurs. A transformation to wavelet features was performed to reduce the dimensionality before the deep learning stage for inferring the medical condition. The performance was validated through 10-fold cross-validation and yielded an average accuracy and sensitivity of 90.23 % and 72.41 %, respectively. The accuracy of discriminating between murmurs' absence and presence reached 76.10 % when evaluated on unseen data. The model had accuracies of 70 %, 88 %, and 86 % in predicting murmur presence in infants, children, and adolescents, respectively. The interpretation of the model revealed proper discrimination between the learned attributes, and AV channel was found important (score 0.75) for the murmur absence predictions while MV and TV were more important for murmur presence predictions. The findings potentiate deep learning as a powerful front-line tool for inferring CHD status in PCG recordings leveraging early detection of heart anomalies in young people. It is suggested as a tool that can be used independently from high-cost machinery or expert assessment.

Major congenital heart defects are rarely diagnosed after newborns' hospital discharge with modern screening.

AIM: Our aim was to assess undiagnosed congenital heart defects (CHD) after newborns' hospital discharge in patients with a murmur or CHD suspicion, to find out the signs that predict CHDs and to estimate the costs of the examinations. METHODS: We reviewed retrospective medical records of patients (n = 490) referred for the evaluation of CHD suspicion during 2017-2018. RESULTS: The median age of the patients was 2.5 (IQR 0.5-7.4) years. Sixty-three (13%) patients had an abnormal echocardiography. Neither ductal-dependent nor cyanotic CHDs were found. Cardiac interventions were performed for 14 out of 63 (22%) patients. Clinical signs indicating CHDs were murmur grade ≥3 (10/11 [91%] vs. 53/479 [11%], p < 0.001) and harsh murmur (15/44 [34%] vs. 48/446 [11%], p < 0.001). Abnormal electrocardiography did not indicate CHD (8/40 [20%] vs. 55/447 [12%], p = 0.165). The total cost of the examinations was 259 700€. The share of the cost of studies assessed as benign was 59%. CONCLUSION: Only a few CHDs were found after newborn hospital discharge among patients who received foetal and newborn screening and were examined due to CHD suspicion. The high number of benign murmurs in children leads to many referrals, resulting in unnecessary healthcare costs.

Evaluation of Heart Murmurs in Children.

This Patient Page describes how heart murmurs may be found in children and what treatment and follow-up may look like if an abnormal murmur is found.

New Onset Cardiac Murmur and Exertional Dyspnea in an Apparently Healthy Child: A Rare Localization of Obstructive Myxoma in the Right Ventricle Outflow Tract without Pulmonary Embolization-A Case Report and Literature Review.

Myxomas are slowly growing benign neoplasms which are rare in children. Up to 80% can be located in the left atrium and generate symptoms such as embolism, cardiac failure, fever and weight loss. Rarely, myxomas can be detected in the right ventricle outflow tract, causing arrhythmias, pulmonary emboli and sudden death. We report the case of a 13-year-old healthy child brought to the Emergency Department (ED) of the Children's Hospital Bambino Gesù, Rome, for recent dyspnea, chest pain on exertion and new onset cardiac murmur. Patient underwent medical examination and echocardiogram with the finding of a rounded and lobulated voluminous mass in the right ventricle outflow tract (RVOT) which caused severe obstruction. The contrast computed tomography (CT) scan confirmed the presence of a heterogeneously enhancing soft-tissue mass occupying the RVOT with no evidence of pulmonary embolization. The mass was surgically excised, and the pathologic examination confirmed our suspicion of myxoma. Our experience suggests that myxoma can have mild clinical symptoms, the presentation may be non-specific, and diagnosis can be a challenge Careful examination and a diagnostic imaging workup, primarily with the transthoracic echocardiogram, are needful to make a rapid differential diagnosis and to better manage surgical treatment and follow-up.

Challenging echocardiographic pictures of aortic arch: when heart murmur leads to a rare diagnosis.

We describe the case of a 2-week-old boy referred for systolic murmur. His echocardiography showed challenging pictures of the aortic arch, which led to the rare diagnosis of arterial tortuosity syndrome.

Reasonable requests: echocardiography referral forms as a measure of coherent clinical communication.

BACKGROUND: Well performed clinical communication is a cornerstone of collaborative care in medicine but may be confounded by inconsistent intentions of the messenger and biased interpretation by the recipient. A comparison of the findings of electronic echocardiography reports with clinician-completed standardised request forms provided an opportunity to assess communication quality. AIM: The study aimed to determine clinician aptitude to complete written echocardiography referral forms by assessing the completeness, appropriateness, accuracy, and coherency of the reported clinical findings, conclusions and requests made on the referral forms. The study explored factors that may influence the quality of communication through this referral medium. METHODS: A retrospective cohort study was conducted on patients who underwent trans-thoracic echocardiography imaging at Cecilia Makiwane Hospital in East London over 26 months. Paper echocardiography request forms that recorded the requesting clinician's findings on examination, the provisional clinical diagnosis, and the specific echocardiographic information sought, were compared with the actual findings on echocardiography. RESULTS: Of 613 request forms reviewed, 97 cases were excluded due to illegibility or because they lacked analysable information or requester details, leaving 516 forms suitable for study. No pathology was found on echocardiography in 31%. Of the murmurs expected from the echocardiography findings, only half were recorded on the request form (sensitivity and positive predictive value both 52%.). Only 35% of request forms that mentioned a mitral systolic murmur gave a working diagnosis of mitral regurgitation and only 38% of request forms that mentioned an aortic systolic murmur considered aortic stenosis. Clinically suspected cardiomyopathy (CMO) had a PPV of 43% and echocardiographic CMO was missed clinically in 41%. Apex beat displacement reported clinically was not associated with echocardiographic LV dilatation in 65% of cases. One-third (34%) of forms reporting murmurs did not request valve function assessment and 17% considering cardiomyopathy did not request left ventricular function assessment. CONCLUSION: Echocardiography request forms highlight vulnerabilities in clinical communication. Specifically, important clinical features were missing and more concerningly, included when unlikely to be present. There was a lack of concordance between recorded clinical findings and postulated diagnoses. Clinicians sometimes appeared unclear about the value or appropriateness of the requested assistance. Greater emphasis on teaching examination and communication skills may foster safer and more efficient use of scarce resources.

Systolic or diastolic CT image acquisition for transcatheter aortic valve replacement - An outcome analysis.

BACKGROUND: Computed tomography (CT) imaging is the standard of care before transcatheter aortic valve replacement (TAVR). The aortic annulus undergoes conformational changes during the heart cycle. Therefore, the image acquisition time point can impact prosthesis sizing and fit. Clinical outcome data are lacking. The aim of this study was to compare systolic and diastolic cardiac CT data acquisition with regard to procedural and clinical outcomes in patients undergoing TAVR for severe aortic stenosis (AS). METHODS: Preprocedural high-pitch helical CT datasets were analyzed in 1954 patients undergoing TAVR between 2013 and 2018 â€‹at our center. Patients were stratified into two groups according to the acquisition heart phase (979 systolic and 975 diastolic). The study was approved by the local ethics committee. RESULTS: Median age was 81.6 [interquartile range 77.5-85.8] years and 964 (49.3%) patients were male. No significant difference was found for the Valve Academic Research Consortium-3 (VARC-3) endpoints of technical failure (systolic, 5.1% vs. diastolic, 5.2%, p â€‹= â€‹0.94) or device failure (systolic, 13.7% vs. diastolic, 13.5%, p â€‹= â€‹0.92). There was no difference in paravalvular regurgitation. All-cause 30-day mortality was comparable (systolic, 3.6% [95% confidence interval, 2.4-4.7%] vs. diastolic, 3.6% [2.4-4.8%], p â€‹= â€‹1.00), while 3-year mortality rates were higher in the diastolic group (Society of Thoracic Surgeons score adjusted hazard ratio, 1.25 [1.07-1.46], p â€‹< â€‹0.01). CONCLUSIONS: While the 30-day technical and clinical outcomes after TAVR are comparable between systolic and diastolic CT imaging, diastolic imaging was associated with higher long-term mortality. Therefore, the data support the guideline recommendation of systolic imaging.

Approach to the Patient with a Murmur.

Patients with valvular heart disease may present with or without symptoms. A thorough cardiac physical examination can identify patients who require further evaluation and management. Although the utility of different cardiac findings varies widely, diastolic murmurs indicate important underlying valvular pathology requiring further investigation, typically with echocardiography. The proper examination of patients with systolic murmurs, the most common murmurs in clinical practice, is fundamental to cost-effective care. We will review the key components of the cardiac examination and findings relevant to functional murmurs, aortic stenosis, mitral valve prolapse and regurgitation, tricuspid regurgitation, hypertrophic cardiomyopathy, aortic regurgitation, and mitral stenosis.