UNIT 31

Heart Diseases in Infancy and Childhood

Heart Murmurs

Physical examination of the cardiovascular system in infancy and childhood does differ
essentially from that in adults, but there are certain aspects that should be highlighted.
Auscultation of the heart is of particular importance as the majority of heart disorders in
childhood are the result of a structural abnormality, when murmurs are usually present. In
most cases of congenital heart disease a heart murmur is heard either on routine examination
or in association with symptoms referable to the cardiovascular system.

Ejection Murmurs
These are the result of turbulence created by flow out of the heart into the great vessels and
are crescendo-descrescendo in character. The length of the murmur varies with the length
of the ejection period. Normally ejection murmurs are heard maximally at the base of the
heart and radiate cranially. The commonest examples are the murmurs of pulmonary and
aortic stenosis. When the stenosis is at valvar level, there will also usually be an early
systolic sound known as an ejection sound which helps to identify the nature of the murmur.

Regurgitant Murmurs
These are caused by the flow from a high pressure to a low pressure area and are
normally pansystolic.
They are the murmurs of atrioventricular valve incompetence and of ventricular septal
defect. At times it may be difficult to distinguish an ejection murmur from a re2,urz.itant
. 0),
-.
murmur, e.g. in atypical mitral incompetence, subaortic stenosis, infundtbular rsten6sis,
and in certain varieties of ventricular septal defect. The site of maximum intensity and
radiation are ordinarily helpful in differentiation. Most regurgitant murmurs are heard best
away from the base of the heart but this rule does not always apply.

Continuous Murmurs

These are the result of turbulence arising from one source and continuing from systole
through the second sound into diastole. They are heard in association with a patent ductus,
a.ortopulmonary collateral arteries, arteriovenous fistulae, and in the venous hum.

To and Fro Murmurs

These are biphasic. There may be a gap between the two elements. The classical to and fro
murmur is that of combined aortic stenosis and incompetence.

Diastolic Murmurs
These may be short or long. They are usually classified as early or mid-diastolic accordin ,
to their time of onset. The early diastolic murmur commences immediately or soon after the
relevant component of the second heart sound and is characteristic of aortic and pulmonary
incompetence. The mid-diastolic murmur commences with the opening of the mitral or
tricuspid valve and represents the flow into the ventricle. Atrial contraction may produce
a late diastolic or presystolic murmur characteristic of mitral stenosis with sinus rhythm.