Innocent Murmurs Research Articles

Inactive Lifestyles Among Young Children With Innocent Murmurs or Congenital Heart Disease, Regardless of Disease Severity or Treatment.

Sedentary lifestyle morbidities are common among children with congenital heart disease (CHD). Understanding the physical activity trajectory from early childhood could enhance timing and effectiveness of interventions. We recruited 154 children (56% male) at 12 to 47 months of age for this prospective, longitudinal, observational study. Physical activity and sedentary behaviour (7-day accelerometry) and motor skill (Peabody Developmental Motor Scales-2) were assessed every 8 months until 5 years of age and then annually. Mixed-effect repeated measures regression models described outcome trajectories across study assessments. Children had innocent heart murmurs (n= 28), CHD with insignificant hemodynamics not requiring treatment (n= 47), CHD treated by catheterization or surgery without cardiopulmonary bypass (n= 31), or CHD treated surgically with bypass (n= 48). Motor skill was age appropriate (Peabody 49.0 ± 8.4), but participants had lower physical activity (143 ± 41 minutes per day) and higher sedentary time (598 ± 89 minutes per day) than healthy peers, starting at 18 months of age. Movement behaviours were not related to treatment group (P > 0.10), and physical activity was below the recommended 180 minutes per day. Over time, physical activity, sedentary time, and motor skills were primarily related to the baseline measure of each outcome (P < 0.001). Children with simple or complex CHD or innocent heart murmurs have increased risk for sedentary lifestyles. Their physical activity and sedentary behaviours are established before 2 years of age, persist until school age, and are unrelated to motor skills. These results emphasize the need for interventions targeting the youngest children seen in cardiac clinics, regardless of diagnoses of CHD or innocent murmur.

Cardiac assessments of bottlenose dolphins (Tursiops truncatus) in the Northern Gulf of Mexico following exposure to Deepwater Horizon oil.

The Deepwater Horizon (DWH) oil spill profoundly impacted the health of bottlenose dolphins (Tursiops truncatus) in Barataria Bay, LA (BB). To comprehensively assess the cardiac health of dolphins living within the DWH oil spill footprint, techniques for in-water cardiac evaluation were refined with dolphins cared for by the U.S. Navy Marine Mammal Program in 2018 and applied to free-ranging bottlenose dolphins in BB (n = 34) and Sarasota Bay, Florida (SB) (n = 19), a non-oiled reference population. Cardiac auscultation detected systolic murmurs in the majority of dolphins from both sites (88% BB, 89% SB) and echocardiography showed most of the murmurs were innocent flow murmurs attributed to elevated blood flow velocity [1]. Telemetric six-lead electrocardiography detected arrhythmias in BB dolphins (43%) and SB dolphins (31%), all of which were considered low to moderate risk for adverse cardiac events. Echocardiography showed BB dolphins had thinner left ventricular walls, with significant differences in intraventricular septum thickness at the end of diastole (p = 0.002), and left ventricular posterior wall thickness at the end of diastole (p = 0.033). BB dolphins also had smaller left atrial size (p = 0.004), higher prevalence of tricuspid valve prolapse (p = 0.003), higher prevalence of tricuspid valve thickening (p = 0.033), and higher prevalence of aortic valve thickening (p = 0.008). Two dolphins in BB were diagnosed with pulmonary arterial hypertension based on Doppler echocardiography-derived estimates and supporting echocardiographic findings. Histopathology of dolphins who stranded within the DWH oil spill footprint showed a significantly higher prevalence of myocardial fibrosis (p = 0.003), regardless of age, compared to dolphins outside the oil spill footprint. In conclusion, there were substantial cardiac abnormalities identified in BB dolphins which may be related to DWH oil exposure, however, future work is needed to rule out other hypotheses and further elucidate the connection between oil exposure, pulmonary disease, and the observed cardiac abnormalities.

Temporal changes in the presence and intensity of innocent cardiac murmurs in clinically healthy Cairn terrier and Dachshund puppies between 4 and 8 weeks of age

AbstractBackgroundSpontaneous week‐to‐week variation in the presence and intensity of innocent cardiac murmurs in individual puppies is unknown.MethodsSixty privately owned, clinically healthy Cairn terrier and Dachshund puppies between 4 and 8 weeks of age were included. All dogs underwent weekly cardiac auscultation at the breeders’ home by a veterinary cardiology specialist using an acoustic stethoscope. On each occasion, a phonocardiogram was recorded with an electronic stethoscope. Furthermore, all dogs were auscultated once at a first opinion veterinary practise and once at the authors’ institution, where they also underwent an echocardiographic examination.ResultsTwo‐hundred and eighty‐one auscultations were conducted on 32 Cairn terriers and 28 Dachshunds, at the breeders’ homes. Innocent murmurs were detected in 19 puppies. Two of these puppies had a detectable murmur on each auscultation. In five of the puppies, the murmur became undetectable during the observation period and in 12 puppies the murmur was intermittently audible. Auscultation at the authors’ institution had an unpredictable effect on murmur presence and intensity. Phonocardiography revealed murmurs in 42 puppies. Interpretation of phonocardiograms by two independent observers showed nearly perfect agreement (κ = 0.859).ConclusionsRemarkable and unpredictable spontaneous week‐to‐week variation was documented in the presence and intensity of innocent murmurs.

Age of puppies at referral to veterinary cardiology specialists for murmur investigation

BackgroundCardiac auscultation is an important screening test at the first health examination of puppies because most clinically relevant congenital cardiac anomalies cause a loud murmur from birth. This retrospective study aimed to investigate the age at which dogs with suspected congenital cardiac anomalies were referred to a veterinary cardiology specialist for murmur investigation. A secondary aim was to establish the time interval between the visit to the cardiologist and the first available murmur documentation. The digital archive of a veterinary teaching hospital was searched for dogs with congenital cardiac anomalies and puppies with innocent murmurs during a 5-year period. Dogs had to be referred because of a murmur, and they had to undergo physical examination and echocardiography by a veterinary cardiology specialist. The health certificate section of the pet passport, and the medical records from the referring veterinarian, were reviewed to identify the date when the murmur was first documented.ResultsOf the 271 included dogs, 94% had a congenital cardiac anomaly and 6% had an innocent murmur. The dogs’ median age was 190 days when they were examined by the cardiologist. Only 10% of the dogs were referred by the breeder’s veterinarian, while 90% of the dogs were referred by the new owner’s veterinarian. The median age of the first available murmur documentation by a first opinion veterinary practitioner was 95 days.ConclusionsOnly 10% of the puppies in the present study were referred to a veterinary cardiology specialist for murmur investigation before they were sold to a new owner. Referral prior to re-homing would have been feasible if the murmur had been detected and documented by the breeder’s veterinarian, if referral was offered by the breeder’s veterinarian and the referral was accepted by the breeder.

Parental anxiety and misperceptions in children with innocent murmurs.

Previous studies in children with innocent murmurs have shown that parental concern is common. Our aim was to assess the level of anxiety among parents of children referred for cardiology evaluation because of an innocent heart murmur and investigate their perceptions about innocent murmurs. A questionnaire was completed by parents before and after consultation. The questionnaire included a six-item short form of the state scale of the Spielberger State-Trait Anxiety Inventory. After the echocardiogram, a detailed consultation was offered including a thorough explanation that the results were normal, as well as a written report. A total of 417 questionnaires were completed by parents of 340 children. Almost half of the parents believed that a heart murmur signifies heart disease or may interfere with child's ability to exercise; 21% of them stated that the siblings should also be investigated irrespective of the presence of a murmur. The mean Spielberger State-Trait Anxiety Inventory questionnaire score before pediatric cardiology consultation was 17.1 ± 4.3 and increased to 22.6 ± 2.8 after the consultation (Wilcoxon P < 0.001). Parents of infants and children with innocent murmurs exhibit moderate levels of anxiety and this condition can be ameliorated significantly after pediatric cardiology consultation. Focused parental education is of paramount importance and the role of pediatric cardiologists is crucial and decisive.

Üfürüm ile Başvuran Çocukların Ekokardiyografi Sonuçlarının Değerlendirilmesi

Amaç: Çocuk kardiyoloji polikliniğimize kardiyak üfürüm nedeni ile gönderilen hastaların kardiyak üfürüm ve ekokardiyografi bulgularının değerlendirilmesi amaçlanmıştır. Materyal ve Metod: Hastaların üfürümleri masum ve patolojik olmak üzere ikiye ayrıldı. Hastalara elektrokardiyografik ve ekokardiyografik değerlendirme yapıldı. Bulgular: Çalışmamıza üfürüm ile başvuran 219 hasta alındı. Hastaların yaş ortalaması 21,61 ± 34,3 ay. Masum üfürümü olan 138 hastada şu an için tedavi gerektirmeyen patent foramen ovale (40 hasta), küçük sekundum atriyal septal defekt (1 hasta) saptandı. Patolojik üfürüm olduğu düşünülen hastaların %96,2’sinde kardiyak patoloji saptanırken, masum üfürüm saptanan hastaların ise hiçbirinde tedavi gereken kardiyak patoloji saptanmadı (p&amp;lt;0.01). Üfürümün ekokardiyografik bulguları ayırt etmedeki belirleyiciliği incelendiğinde: Çocuk kardiyoloji hekimleri için fizik muayenenin duyarlılığı %66, seçiciliği %97, pozitif tahmini değeri %96, negatif tahmini değeri %83 ve doğruluk oranı %80 iken, genel çocuk uzmanlarının duyarlılığı %57, seçiciliği %87, pozitif tahmini değeri %84, negatif tahmini değeri %64 ve doğruluk oranı %71 idi Sonuç: Çocuk kardiyoloji uzmanları ile genel çocuk hekimleri arasındaki fizik muayene ile kardiyak patoloji saptama oranı arasındaki fark fizik muayenenin ne kadar önemli olduğunu bir kez daha göstermektedir. Genel çocuk hekimlerinin kardiyak muayene konusunda çok iyi eğitilmeleri ile ailelere verecekleri sağlıklı bilgi sayesinde aileleri ve çocukları gereksiz stresten uzak tutacak ve hastaları hayatlarının ilerleyen dönemlerinde geri dönüşümsüz olabilecek kardiyak patolojilerden korumuş olacaklardır.

Catheter Closure of Clinically Silent Patent Ductus Arteriosus Using the Amplatzer Duct Occluder II-Additional Size: A Single-Center Experience.

ObjectivesTranscatheter closure is the treatment of choice for most patent ductus arteriosus (PDA) in infants, children, and adults. However, there is a controversy regarding transcatheter closure of clinically silent PDAs. Some authors favor device closure to eliminate the lifelong risk of infective endarteritis while others recommend avoiding PDA closure in such patients. The study describes our experience of closing the silent PDAs using the Amplatzer duct occluder II-additional size (ADO II-AS) (St. Jude Medical Corp, St. Paul, MN).Materials and methodsFrom April 2018 through March 2021, 52 consecutive pediatric patients aged 18 years and less with clinically silent PDA who had transcatheter closure at our center were enrolled. Patients were excluded if they had clinically detected PDAs; had surgical ligation of PDA with no residual shunt; had left heart dilatation on echocardiography; or moderate-sized PDAs closed with ADO II-AS. In addition, patients with an innocent murmur or murmur due to an associated lesion were included. This study was retrospective, and all of the 52 patients underwent PDA device closure using ADO II-AS.ResultsFifty-two consecutive patients were enrolled with a median age of 17 months, range (97-2.5) 94.5 months. Mean weight was 11.29 kilogram, range (24.8-3.5) 21.3 kilogram, and mean follow-up was 13.5 months, range (29-0) 29 months. Thirty-one (59.6%) were females, and 21 (40.4%) were males. The mean procedure time was 30.6 min, range (60-10) 50 min, and mean fluoroscopic time was 5.5 min, range (28-1.7) 26.3 min. The mean volume of contrast given was 9.1 milliliter, range (30-4) 26 milliliter. Forty-five (45; 88.2%) patients had immediate closure of PDA. No patients had anesthetic or vascular complications; however, two patients had procedural complications. Device placement was unsuccessful in one patient with Downs syndrome. The mean follow-up for our patients was 13.5 months, range (29-0) 29 months; the patients were asymptomatic at the follow-up, and none of the patients had any residual leak. None of the patients showed coarctation or left pulmonary artery stenosis at the latest follow-up.ConclusionThe usefulness of catheter-based therapy for silent PDA is less well-established by current evidence. Further studies are needed to justify the intervention solely based on the premise that the silent duct is a substrate for infective endarteritis; however, our reason to close silent PDA was to do so primarily because of social reasons. This study found that device closure of silent PDA is safe and effective using an ADO II-AS device with minimal risk of embolization and a low residual shunt rate. Coils have been used to close small PDAs, however, with higher rates of embolization and device malpositioning. We believe ADO-II AS offers an advantage of safety and efficacy over coils. In addition, the study highlights the advantage of using an ADO II-AS device, which can be delivered via a four French delivery system with no arterial complications.

Anxiety levels in parents of asymptomatic neonates and young infants referred for echocardiography

ABSTRACT Introduction Previous studies in children with innocent murmurs have shown that parental concern is common. Methods We assessed the anxiety levels among parents of asymptomatic neonates or infants up-to 6 weeks referred for cardiologic consultation because of a heart murmur. A six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) was completed by the parents before and after consultation. Results The average STAI score decreased from 14.42 ± 4.54 on arrival to 9.69 ± 4.26 after the consultation (p < 0.001). Overall, the parents felt more calm, less tense, less upset, more relaxed, more content and less worried after the consultation (p < 0.001). Multivariable linear regression analysis showed that the STAI score prior to consultation was related to infants age (coefficient β = – 0.172; P = 0.046) and STAI score post consultation was related to the final diagnosis (β = 0.312; P < 0.001). Conclusion In conclusion, parents of asymptomatic neonates and young infants with a murmur exhibit moderate levels of anxiety which can be ameliorated after consultation. Parental education in the field is of paramount importance and the role of both paediatric cardiologists as well as primary care physicians is crucial and decisive.

Blood pressure and heart rate monitoring in children and adolescent with Still's vibratory murmur.

Innocent heart murmur is common in healthy infants, children and adolescents. Although most cases are not pathologic, a murmur may be the manifestation of cardiovascular disease. It may also cause or be an indicator of blood pressure (BP) and heart rate (HR) changes. This study aimed to document changes in BP and HR in children with Still's vibratory murmur (SVM). This study included 226 children with SVM, and the control group included 138 healthy children that were age-, height- and weight-balanced. Patient files and our hospital registry system were retrospectively investigated for laboratory findings and electrocardiography and echocardiography results. In addition, we prospectively performed 24-h ambulatory BP monitoring in both groups. There were no statistically significant differences in 24-h, daytime and nighttime systolic BP, 24-h and nighttime diastolic BP and nighttime HR between the patient and control groups (P = ns). However, daytime diastolic BP, mean HR and daytime HR were significantly higher in patient group (P = 0.009, 0.039 and 0007, respectively). We believe that in the presence of a higher HR and a higher aortic diastolic BP, which may induce hemodynamic changes in the left ventricle, flow turbulence through the aortic valve may increase, increasing the probability of hearing a murmur. ambulatory BP monitoring could be useful to obtain a better picture of these parameters during the 24-h period.

Cardiac Examination and Evaluation of Murmurs.

1. Vincent J. Gonzalez, MD, MS* 2. William B. Kyle, MD* 3. Hugh D. Allen, MD* 1. *Section of Pediatric Cardiology, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX * Abbreviations: PDA: : patent ductus arteriosus VSD: : ventricular septal defect Murmurs are an exceedingly common physical examination finding in pediatric patients. It is imperative that all pediatricians know how to perform a complete cardiac examination and understand the components of benign versus pathologic murmurs. After completing this article, readers should be able to: 1. Review and perform a complete cardiac examination in the pediatric patient. 2. Understand the various heart sounds and how they correlate with the underlying physiology of the cardiac cycle. 3. Accurately describe a murmur and be able to discern between innocent and pathologic murmur findings. The evaluation of murmurs in the pediatric patient has remained a subject of both interest and anxiety for decades. Murmurs are one of the most common physical examination findings in children, and most youth will have a murmur at some point in their life. Given that most murmurs are innocent, it is prudent to differentiate these benign murmurs from those representing underlying cardiac disease. However, with advancements in medical technology and the widespread availability of echocardiography, there is concern about a concomitant decline in cardiac examination skills. This not only has come at great financial expense to the health-care system but also may result in unnecessary increased parental or patient anxiety. In addition to the physical examination, a targeted cardiac history is essential in determining whether to reassure or raise concern when evaluating the pediatric patient with a murmur. Special attention should be given to the family history; maternal pregnancy information, including the presence of gestational diabetes or drug/toxin exposures in utero, history of prematurity, growth, and feeding patterns; comorbid conditions; and developmental milestones. For older children it is also important to characterize any history of palpitations, presyncope or syncope, chest discomfort, and activity intolerance. Taking this into account, this review is designed to provide an overview of the cardiac physical examination in the …

Kaposi's sarcoma revealing an immune restoration syndrome

Introduction: Highly active antiretroviral therapy (HAART) leads to reconstitution of immune responses in HIV-infected patients. This immune reconstitution may reveal an immune reconstitution syndrome (IRS). While tuberculosis is the most common manifestation of IRS in southern countries, other more serious conditions such as Kaposi's disease may reveal it. Observation: We report a case of Kaposi's disease revealing an immune restoration syndrome with the aim of contributing to a better management. The patient was 38 years old and HIV1 positive, severely immunocompromised with a TCD4 lymphocyte count of 138 cells/mm3. He was admitted to the YO University Hospital for fever associated with a progressive deterioration of the general condition. On admission, he showed signs of anemic cardiomyopathy (functional systolic murmur + edema of the lower limbs + severe anemia at 4.7g/dl) and signs of functional renal failure (creatinine=182 micromol/l). Under treatment, the evolution was favorable and he was discharged from the hospital on antiretroviral treatment (ARV). Three months after the start of ARV treatment, the follow-up assessment noted an increase in TCD4 lymphocytes to 300 cells/mm3 and the skin examination revealed Kaposi's lesions on the thigh. With specific treatment, the evolution was favorable. Conclusion: Early detection and management of HIV infection can prevent some serious manifestations of immune restoration syndrome, such as Kaposi's disease.

버그 알고리즘을 이용한 청진음의 음향학적 분석법에 관한 연구

This study describes an acoustic analysis method of stethoscope signal using the Burg algorithm which is a kind of linear prediction, considering the heartsound production mechanism is linear and can be modelled by an inverse filter of the all-pole model. For this study, normal and heart diseased stethoscope sounds were collected in the pediatrics of an university hospital. The collected signals were preprocessed by noise filtering and analyzed by the Burg algorithm, a kind of linear prediction. The AR spectra and the formants for the heartsounds for the normal and the diseased children are estimated and the results are compared. The spectra showed outstanding differences in morphology and formant frequencies between the normal and the diseased children. Normal children showed relatively low frequency of F1(the first formant) and small negative slope from F1. VSD children revealed stiff slope change around F1 to F3. Spectra of ASD children is similar with the normal case, but have negative values of F3. F1-F2 difference of the functional murmur children were relatively large.

Cardiac murmur in a neonate: how significant is it?

Background: There is a popular belief that cardiac murmurs are common in neonate and most are innocent or physiological. However, a cardiac murmur may be the first sign of a serious structural cardiac disease in neonate. Objective of study was conducted to determine the clinical significance of cardiac murmur as a sole clinical sign in neonate.Methods: 100 neonates having cardiac murmur were selected from neonatal intensive care unit of department of pediatrics BJMC Ahmedabad from June to November 2019. Murmurs were clinically classified as innocent or significant murmur. Echocardiography was done at UN Mehta institute of cardiology for confirmation of the diagnosis and then patients were reclassified as innocent murmur and structural heart defect. structural heart defects were further subdivided into physiological variant or significant heart defect.Results: Amongst 100 neonates studied, sixty two percent cases with murmur were found to have structural heart defect and 38% had innocent murmur. Among the cases with structural heart defect. 65.3% were found to have significant heart defect and 34.7% were physiological variant. Clinical suspicion was able to differentiate innocent murmur or structural heart defect (p&lt;0.05) as well as physiological variant versus significant heart defect (p&lt;0.05).Conclusions: Confident diagnosis of heart disease in the newborn period on clinical examination is probably possible by pediatricians or neonatologists. However, for confirmation of diagnosis, early echocardiographic evaluation is necessary.

Heart Murmurs

Key Points A Heart murmur results from turbulent blood flow. A complete history and physical examination are most important for evaluating a cardiac murmur. The intensity of a murmur does not necessarily reflect the severity of abnormality. Innocent murmurs are systolic, less than grade 3 in intensity, and louden when the patient moves from an upright position to a supine position. Electrocardiography and echocardiography are usually performed to define the cause of a pathological murmur.

Pathological discrimination of the phonocardiogram signal using the bispectral technique.

Phonocardiography is a dynamic non-invasive and relatively low-cost technique used to monitor the state of the mechanical activity of the heart. The recordings generated by such a technique is called phonocardiogram (PCG) signals. When shown visually, PCG signals can provide more insights of heart sounds for medical doctors. Thus, several approaches have been proposed to analyse these sounds through PCG recordings. However, due to the complexity and the high nonlinear nature of these recordings, a computer-assisted technique based on higher-order statistics HOS is shown to be, among these techniques, an important tool in PCG signal processing. The third-order spectra technique is one of these techniques; known as bispectrum, it can provide significant information to support physicians with an accurate and objective interpretation of heart condition. This technique is implemented and discussed in this paper. The implemented technique is used for the analysis of heart severity on nine different PCG recordings. These are normal, innocent murmur, coarctation of the aorta, ejection click, atrial gallop, opening snap, aortic stenosis, drum rumble, and aortic regurgitation. A unique bispectrum representation is generated for each type of heart sounds signal. Then, based on the bispectrum analysis, fifteen higher-order spectra HOS features such as the bispectral amplitude, the entropies, the moments, and the weighted center are extracted from each PCG record. The obtained HOS-features showed a well-correlated evolution with the increasing importance of heart severity leading therefore to a high potential in discriminating pathological PCG signals. One should know that, generally, classification of pathological PCG signals refers to the distinction between the presence of a pathology from its absence (binary response) while the discrimination considered in this paper provides an analogue response (value) which can vary from one pathology to another in an increasing or decreasing way.

Standardization of Dolphin Cardiac Auscultation and Characterization of Heart Murmurs in Managed and Free-Ranging Bottlenose Dolphins (Tursiops truncatus).

Cardiac auscultation is an important, albeit underutilized tool in aquatic animal medicine due to the many challenges associated with in-water examinations. The aims of this prospective study were to (1) establish an efficient and repeatable in-water cardiac auscultation technique in bottlenose dolphins (Tursiops truncatus), (2) describe the presence and characterization of heart murmurs detected in free-ranging and managed dolphins, and (3) characterize heart murmur etiology through echocardiography in free-ranging dolphins. For technique development, 65 dolphins cared for by the Navy Marine Mammal Program (Navy) were auscultated. The techniques were then applied to two free-ranging dolphin populations during capture-release health assessments: Sarasota Bay, Florida (SB), a reference population, and Barataria Bay, LA (BB), a well-studied population of dolphins impacted by the Deepwater Horizon oil spill. Systolic heart murmurs were detected at a frequent and similar prevalence in all dolphin populations examined (Navy 92%, SB 89%, and BB 88%), and characterized as fixed or dynamic. In all three populations, sternal cranial and left cranial were the most common locations for murmur point of maximal intensity (PMI). An in-water transthoracic echocardiogram technique was refined on a subset of Navy dolphins, and full echocardiographic exams were performed on 17 SB dolphins and 29 BB dolphins, of which, 40 had murmurs. Spectral Doppler was used to measure flow velocities across the outflow tracts, and almost all dolphins with audible murmurs had peak outflow velocities ≥1.6 m/s (95%, 38/40); three dolphins also had medium mitral regurgitation which could be the source of their murmurs. The presence of audible murmurs in most of the free-ranging dolphins (88%) was attributed to high velocity blood flow as seen on echocardiography, similar to a phenomenon described in other athletic species. These innocent murmurs were generally characterized as Grade I-III systolic murmurs with PMI in the left or sternal cranial region. This study is the first to describe an efficient technique for in-water dolphin cardiac auscultation, and to present evidence that heart murmurs are common in bottlenose dolphins.

A heart murmur - a frequent incidental finding

A heart murmur - a frequent incidental finding Abstract. Heart murmurs are very common and are present in up to 80 % of school children and 52 % of adults. They originate from the transition from laminar to turbulent blood flow in patients with a structural cardiomyopathy (so-called "organic" murmurs) or in patients with normal hearts (so-called "innocent" murmurs). A detailed history and physical examination help to discriminate innocent from organic murmurs. With the wide availability of transthoracic echocardiography (TTE) cardiac auscultation has lost a lot of its importance, although it remains an important skill for the initial evaluation and triage. An innocent murmur is a minor (1 / 6 - 2 / 6), crescendo-decrescendo, mostly position-dependent, mid-systolic murmur without radiation, which needs no further workup in asymptomatic patients with normal physical capacity. A TTE should be ordered if signs for a cardiac disease are present based on history, physical examination or other tests. Diastolic and continuous murmurs are mostly pathologic and warrant further workup.

When Clinical Judgement of a Heart Murmur is Wrong: A Case Report

Abstract Background: Infants with congenital heart defects (CHD) are at risk of death if not recognized and treated on time, desirable during intrauterine life or soon after birth. Case: A 6-week old infant presented for the evaluation of an innocent murmur, discovered immediately after birth and recorded by the neonatologist, family physician and pediatrician at follow-up visit. At physical examination, a grade 2/6 systolic murmur and tachycardia were observed. The electrocardiography revealed sinus tachycardia. Transthoracic echocardiography recorded multiple heart defects (three ventricular septal defects, an atrial septal defect, valvular regurgitations, impaired right heart function) and a vascular defect. Treatment consisted of surgical repair. Conclusions: The rarity of the case results from the atypical presentation of the cardiovascular defects only through an innocent heart murmur, therefore criteria requested by guidelines for evaluation through transthoracic echocardiography for the suspicion of a CHD, were not encountered and the diagnosis was delayed.

49. IMPLEMENTATION AND UTILITY OF A PHONE-BASED APPLICATION FOR TEACHING AUSCULTATION SKILLS TO INCOMING PEDIATRIC CARDIOLOGY FELLOWS

Background Mastery of cardiac auscultation is a core component of cardiology training. New computer-based auscultation teaching tools have been developed to help teach this skill to trainees. OBJECTIVE: To assess incoming pediatric cardiology fellows’ auscultation skills and evaluate a phone-based application (app) to teach auscultation. Methods At the annual national Pediatric Cardiology Fellows’ Boot Camp at Stanford, the eMurmur© app was utilized to teach core auscultation skills to incoming pediatric cardiology fellows. In groups of 5 trainees each, attendees were taught basic auscultation skills in 30-minute blocks. Auscultation teaching centered around distinguishing innocent (INN) vs pathological murmurs (PATH) and focused on key diagnoses and murmurs most frequently encountered by pediatric cardiologists. Pre- and post-training assessments and surveys [Likert scoring 1-5] were administered to all attendees and were analyzed via paired t-test and sign rank test. Results A total of 40 incoming cardiology fellows from 35 training programs attended the Boot Camp at Stanford University in Palo Alto, CA from June 1-3, 2019. All trainees completed the pre- and post-training assessments. Prior to the course, trainees were less likely to correctly distinguish innocent murmurs vs. pathologic murmurs (INN 77 ± 26 % vs. PATH 92 ± 11%; p = 0.001). 73% of trainees reported the auscultation session improved their auscultation skills. Though there was no difference in overall test scores (PRE 82 ± 16% vs. POST 85 ± 17%; p = 0.13), after the training the trainees’ self-reported comfort in identifying the auscultatory findings for the most common lesions seen in pediatric cardiology were higher (PRE 3.3 ± 0.9 vs. POST 3.8 ± 0.8; p = 0.03). Comfort scores improved most for distinguishing systolic vs. diastolic murmurs (PRE 3.7 ± 0.7 vs. POST 4.1 ± 0.6 POST; p = 0.05) and gallops (PRE 3.3 ± 0.09 POST 3.8 ± 0.7; p = 0.005). Conclusions The use of an app-based teaching tool is an effective method to teach auscultation skills to incoming pediatric cardiology fellows. The app can improve fellows’ comfort with identifying the most common lesions seen in pediatric cardiology.

Nonauscultatory clinical criteria are sensitive for cardiac pathology in low-risk paediatric heart murmurs.

Healthy children with likely innocent heart murmurs are frequently referred to cardiologists for reassurance. Existing guidelines that advise against these referrals are not consistently followed partly because they involve subjective auscultatory judgements with which many care providers are uncomfortable. Here, we investigate whether clinical criteria with no subjective auscultatory component are sensitive for cardiac pathology. A retrospective chart review was performed of all new patients seen in our paediatric cardiology clinic for assessment of a murmur from January 1, 2016 through June 30, 2018. Patients were characterized as "low-risk" if they met all of the following criteria: asymptomatic; normal physical examination other than the murmur; no risk factors for congenital heart disease; and age over 12 months. The primary outcomes were the sensitivity for ruling out pathology and the negative predictive value of the proposed criteria. Of 915 total patients, 214 met the low-risk criteria. The sensitivity of our criteria for ruling out pathology was 97.2% (95% confidence interval 94.1% to 99.0%) and the negative predictive value was also 97.2% (95% confidence interval 94.0% to 98.7%). Six of the 214 low-risk patients had pathology (2.8%; 95% confidence interval 1.3% to 6.0%), none of which has required intervention since diagnosis. Each of these six children had a murmur that sounded pathological to the auscultating cardiologist. Basic clinical criteria that do not require auscultation are highly sensitive for ruling out significant cardiac pathology in children over 12 months of age.