Murmurs In Children Research Articles

Automated analysis of heart sound signals in screening for structural heart disease in children.

The algorithm was able to distinguish murmurs associated with structural cardiac anomalies from innocent murmurs with good sensitivity and specificity. The algorithm was unable to identify heart defects that did not cause a murmur. Further research is needed on the use of the algorithm in screening for heart murmurs in primary health care. • Innocent murmurs are common in children, while the incidence of moderate or severe congenital heart defects is low. Auscultation plays a significant role in assessing the need for further examinations of the murmur. The ability to differentiate innocent murmurs from those related to congenital heart defects requires clinical experience on the part of general practitioners. No AI-based auscultation algorithms have been systematically implemented in primary health care. • We developed an AI-based algorithm using a large dataset of sound samples validated by echocardiography. The algorithm performed well in recognizing pathological and innocent murmurs in children from different age groups.

Серцеві шуми в дітей

У лекції розглянуто питання оцінки аускультативної картини серцевих шумів у дітей. Проаналізовані класифікація кардіальних шумів у дітей, механізми виникнення органічних і функціональних шумів. Зокрема, описано їх диференціювання за такими показниками, як фаза їх виникнення, епіцентр шуму, інтенсивність, тембр, іррадіація, залежність від фаз дихання, від положення дитини, від фізичного навантаження та ін. Акцентовано увагу на тактиці лікаря при виявленні різних серцевих шумів у дітей.

Diagnosis of cardiac murmurs in children

Heart murmurs are frequently heard, and the murmurs are the usual cause for uncovering heart defects in pediatric patients. The murmurs are grouped into systolic murmurs, diastolic murmurs, and continuous murmurs. Cautious assessment of the murmur and associated abnormalities in physical examination are likely to produce correct diagnosis of the cause of the murmur. Sometimes it may be necessary to utilize noninvasive and invasive (rarely) investigations to achieve an accurate diagnosis. Nonetheless, such diagnostic studies may frequently be required for quantification, and before intervention either by transcatheter methods or by surgery.

Evaluation and diagnostic approach for heart murmurs in children

Heart murmurs are common in children. Most of them are innocent murmurs with normal heart anatomy and function, and only a few are pathologic murmurs with congenital heart anomaly or abnormal heart function. However, a heart murmur may be the sole symptom of serious heart disease. Therefore, careful evaluation of heart murmurs for distinguishing pathologic murmurs from innocent murmurs is important. Heart murmurs are described by their intensity, timing in the cardiac cycle, location, transmission, and quality. Murmurs, such as a holosystolic or diastolic murmur, of grade 3 or higher intensity, harsh quality, an abnormal S2, a systolic click, or increased intensity when the patient stands are more likely to be pathologic murmurs. Innocent murmurs are more likely to be systolic murmurs, with soft sounds, short duration, low pitch, and varying intensity with phases of respiration and posture (disappears with standing). Not only auscultation but also physical examination findings are important to evaluate heart murmurs. The gold standard test for the evaluation of any potentially pathologic murmur is echocardiography. For the appropriate use of echocardiography, close physical examination, including auscultation, is essential and requires considerable practice.

Intelligent Diagnosis of Heart Murmurs in Children with Congenital Heart Disease.

Heart auscultation is a convenient tool for early diagnosis of heart diseases and is being developed to be an intelligent tool used in online medicine. Currently, there are few studies on intelligent diagnosis of pediatric murmurs due to congenital heart disease (CHD). The purpose of the study was to develop a method of intelligent diagnosis of pediatric CHD murmurs. Phonocardiogram (PCG) signals of 86 children were recorded with 24 children having normal heart sounds and 62 children having CHD murmurs. A segmentation method based on the discrete wavelet transform combined with Hadamard product was implemented to locate the first and the second heart sounds from the PCG signal. Ten features specific to CHD murmurs were extracted as the input of classifier after segmentation. Eighty-six artificial neural network classifiers were composed into a classification system to identify CHD murmurs. The accuracy, sensitivity, and specificity of diagnosis for heart murmurs were 93%, 93.5%, and 91.7%, respectively. In conclusion, a method of intelligent diagnosis of pediatric CHD murmurs is developed successfully and can be used for online screening of CHD in children.

Cardiac Murmurs in Children: A Challenge For The Primary Care Physician.

Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause. Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination. In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.

Innocent heart murmurs and enuresis: Examining a possible link.

The aim of this study was to evaluate the prevalence of innocent heart murmurs in children affected by nocturnal enuresis (NE). The prevalence of innocent heart murmurs in G2 was 6.34%. This condition was significantly more frequent in children who suffered from NE. Indeed, in G1, the prevalence of innocent heart murmurs was 21.45%, although there were few differences between the children with monosymptomatic NE and non-monosymptomatic NE; moreover, this prevalence was higher in males. We enrolled a total of 401 children (G1), 300 males and 101 females, aged 5-15 years, affected by NE and referred to the Service of Pediatrics, "Campus Bio-Medico" University Hospital of Rome, from September 2013 to September 2018, into the study. The control group was composed of 394 children without NE (G2). The study was carried out in compliance with the Helsinki Declaration. These findings made us aware of the presence of possible underlying mechanisms, which explain the association between a higher prevalence of innocent heart murmurs and enuresis, and further studies are required to explore this issue.

Heart murmurs in children – when to worry?

In the cardiac ultrasound era, cardiac murmurs are one of the most frequent causes of referral to a pediatric car­dio­lo­gist. However, most of the cardiac murmurs in chil­dren are benign. This study represents an overall approach by highlighting the main characteristics of innocent mur­murs that do not require further investigations, in com­pa­ri­son to those in which is compulsory to perform a cardiac ultrasound. Moreover, cardiac murmurs were clas­sified according to their localization and child’s age.

Computer-aided auscultation of murmurs in children: evaluation of commercially available software.

Heart murmurs are common in children and may represent congenital or acquired cardiac pathology. Auscultation is challenging and many primary-care physicians lack the skill to differentiate innocent from pathologic murmurs. We sought to determine whether computer-aided auscultation (CardioscanTM) identifies which children require referral to a cardiologist. We consecutively enrolled children aged between 0 and 17 years with a murmur, innocent or pathologic, being evaluated in a tertiary-care cardiology clinic. Children being evaluated for the first time and patients with known cardiac pathology were eligible. We excluded children who had undergone cardiac surgery previously or were unable to sit still for auscultation. CardioscanTM auscultation was performed in a quiet room with the subject in the supine position. The sensitivity and specificity of a potentially pathologic murmur designation by CardioscanTM - that is, requiring referral - was determined using echocardiography as the reference standard. We enrolled 126 subjects (44% female) with a median age of 1.7 years, with 93 (74%) having cardiac pathology. The sensitivity and specificity of a potentially pathologic murmur determination by CardioscanTM for identification of cardiac pathology were 83.9 and 30.3%, respectively, versus 75.0 and 71.4%, respectively, when limited to subjects with a heart rate of 50-120 beats per minute. The combination of a CardioscanTM potentially pathologic murmur designation or an abnormal electrocardiogram improved sensitivity to 93.5%, with no haemodynamically significant lesions missed. Sensitivity of CardioscanTM when interpreted in conjunction with an abnormal electrocardiogram was high, although specificity was poor. Re-evaluation of computer-aided auscultation will remain necessary as advances in this technology become available.

Evaluation of Diagnostic Methods in the Differentiation of Heart Murmurs in Children

Introduction:The most common clinical sign in pediatric cardiology is a heart murmur (organic and inorganic). Organic are sign of heart disease, while inorganic (basically divided into accidental and functional) murmurs occur on anatomically healthy heart.Aim:To determine the justification of the application of the methods of cardiac treatment.Patients and methods:Study included 116 children aged from 1 to 15 years, who were referred due to cardiac treatment to Pediatric Clinic, of Sarajevo University Clinical Center.Results:The first group consisted of children with innocent heart murmur, 97 (53 males). The second group consisted of patients with organic murmur, 19 (13 males). The average age of the first group was 7.69 (1.01–15.01) years old, and of the second group 3.15 (1.01- 8.06) years old, and there is a significant difference between these two groups (p <0.001). Medical history questions about potentially harmful habits of mother in pregnancy, found significant differences in the frequency of the existence of habits between the first and second groups of subjects (14.44% vs. 85.1%, p = 0.013). The values of the pulse of patients showed statistically significant difference (p = 0.012). The most common place of the murmurs’ appearance is the second left intercostal space. In the first group, the most common were vibratory (32.3%) and ejection (31.9%) and in the second the most common were holosystolic (73.7%) murmur. Analyzing the R/S ratio of V1, a significant difference among the two groups was found (mean 0.78 vs. the values for 1.45, p = 0.003). There is a significance in terms of developed hypertrophy of the heart cavities (BVH) between the two groups. The most common accidental murmur was classic vibratory Still’s murmurs (55.43%) and the most common congenital heart defects was ASD (36.8%).Conclusions:A heart murmur itself, should not be the purpose of auscultation. One of the tasks of pediatricians, pediatric cardiologists in particular would be to improve auscultation, as a sovereign method of heart murmurs assessment. Heart murmur assessment should be adapted to recognize whether heart murmur is innocent, or there is suspected or probable congenital heart defect.

Parental anxiety related to referral of childhood heart murmur; an observational/interventional study.

BackgroundDetection of a heart murmur in healthy children is common, but may generate anxiety among parents. Many parents believe a heart murmur is a sign of heart disease, although the majority of heart murmurs are innocent. The purpose of this study was to assess anxiety and concerns in parents of children referred for evaluation of a heart murmur and to evaluate the effect of receiving a fact sheet about heart murmurs before the cardiologic consultation.MethodsParents of children referred for evaluation of a heart murmur responded to questionnaires assessing family and patient characteristics, parental concerns and anxiety. Anxiety was measured using the State Trait Anxiety Index (STAI) before and two weeks after the consultation. One third of the parents received a fact sheet before the consultation.ResultsTwo hundred fifty-eight parents of 178 children participated. About 60 % of the parents had an increased level of anxiety before the consultation. The majority of the parents (71 %) had at least one major concern about heart murmurs in children, and having a concern was related to higher anxiety levels (p = 0.02). Anxious personality and lower education predicted an increased anxiety level. Before the consultation, parents who received a fact sheet presented a lower mean STAI state anxiety level (33.2) than those who did not (35.3), but the difference was not significant (p = 0.09). Fewer parents in the intervention group believed their child would have increased risk of heart disease later in life (p = 0.04) or that heart murmurs in children represents valvular-or congenital heart disease (p = 0.02). After the consultation, parental anxiety decreased from a mean STAI state of 34.9 to 30.6 (p < 0.01), and the mean STAI state scores were similar for the control and intervention group.ConclusionParents with a child referred for a heart murmur presented a higher mean anxiety level than pre-school parents, and having an anxious personality, a major concern or low education predicted an increased anxiety level. After the consultation, parental anxiety decreased. Receiving a fact sheet about heart murmurs did not significantly reduce parental anxiety levels, but had a modest effect on concerns for the consequences of a heart murmur.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-015-0507-4) contains supplementary material, which is available to authorized users.

G92(P) Paediatric cardiac murmur guideline for the children’s emergency department

<h3>Aim</h3> To develop a paediatric cardiac murmur guideline for a Children’s emergency department (CED), following mismanagement of 2 cases of heart murmurs in children. Currently there is no national guideline in place. <h3>Methods</h3> Electronic databases Medline, Embase, Cochrane Cinahl, Psycinfo, Amed, British nursing index, DARE and CENTRAL were searched using title/abstract terms and subject headings: heart/cardio/cardia/murmur/sound AND diagnosis/assessment/evaluation/examination. Results were limited to children aged 0–18 years and no limitations placed on date or language. The results were exported on to Mendeley workstation and analysed. <h3>Results</h3> Medline returned 1204 results, Embase (1168), Cochrane (0), Cinahl (131), Psycinfo (15), Amed (13), British nursing index (5), DARE (0) and CENTRAL (8). When duplicates were removed 2533 results remained from which 560 articles were selected according to suitability. Among these 100 original papers were fully accessed and reviewed. Based on the available evidence a guideline triaging patients into a traffic-light system according to clinical severity with an algorithm for investigation was developed, taking into account patient feedback and opinions from experts in the field (Figures 1 and 2). <h3>Conclusion</h3> A new, easy to follow guideline has been implemented, which will aid clinicians to confidently triage children presenting with murmurs according to clinical need and guide appropriate management. This will promote quality of care and patient safety, and facilitate the management of children with murmurs who attend the CED.

OP-069 Clinical and Echocardiographic Evaluation of Silent Carditis in Children with Rheumatic Fever

Differential Diagnosis of Innocent Heart Murmurs In Children. Zijo Begic, Edin Begic, Nedim Begic. Pediatric Clinic, CCU Sarajevo, Sarajevo, Bosnia and Herzegovina; Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina. Introduction: Heart murmurs in children are the most common reason for specialist cardiac treatment. Evaluation of heart murmur represents exclusion or existence of congenital anomalies of the heart. Normal anatomical and functional findings of heart must be proven with clinical examination, electrocardiography (ECG), as well as X-ray diagnostics, laboratory diagnostics, less often with echocardiography, and other noninvasive and invasive methods. There are organic, functional, and innocent murmurs. Objectives: The main objective was to show the frequency and significance of innocent heart murmurs in children. Study was made in order to show the wrong trend in modern medicine, the neglect of classical detection methods, primarily auscultation. Material-Methods: The study included 1827 patients who were treated at the Health Centre “Dom zdravlja Breza”, in Breza (primary health care), Bosnia and Herzegovina, from January till 20th December 2014. This study had prospective and analytical character. Results: Heart murmurs were registered in 251 (13,7%) patients, in 203 (80,8%) that was an accidental finding, while 48 (19,2%) had symptoms that could be linked to the cardiovascular disorder. In 63 (25%) patients ECG was done (doctor/ parent request), in 19 complete X-ray of the heart and lungs, and 11 patients underwent additional laboratory tests. Ultrasound evaluation was performed in 50 (19,9%) patients, and on 8 (3,1%) patients abnormal findings have been observed (mainly for monitoring). Two patients had indication for cardiovascular/ interventional procedure (ostium secundum atrial septal defect 10.6 mm and ductus arteriosus persistens 2.8 mm). Conclusion: In everyday practice, clinical diagnosis and differential diagnosis of heart murmurs in children are based mainly on the use of auscultation of the heart. Echocardiography should not be routine, initial method. It is necessary to adjust the treatment of heart murmurs, with assessment of whether it is innocent heart murmur, suspected congenital heart defect or probable congenital heart defect. Given that most of the heart murmurs are innocent, family doctors and paediatricians, should be trained to recognize heart murmurs, so knowledge could rationalize sole use of expensive diagnostic methods.

Heart murmurs in children. When to refer?

Heart murmurs in children. When to refer?

Sopro cardíaco pediátrico: estudo de série de casos

Introduction: Heart murmurs are detected in many children. They are a common cause of referral and it is important to be aware of the warning signs for significant murmurs when evaluating a child with a heart murmur. Purpose: To analyze the population referred to a Pediatric Cardiology Department with a cardiac murmur. Material and Methods: This is a study of a case series of children referred for investigation of a cardiac murmur. The authors reviewed the cases referred between January to March 2012 with the diagnosis of heart murmur, assessing demographic data, clinical history, physical findings, and the results of laboratory tests, including transthoracic echocardiography and electrocardiography. Results: During the study period, there were a total of 743 first consultations. In 197 children (26.5%) a heart murmur was the reason for referral. Of the sample, 51.3% were male and the majority (about 70%) of patients were younger than 2 years. In almost all of the children the murmur was described as innocent and there were no other significant finding on physical examination. In about one third of cases, anomalies were found with echocardiographic assessment. There was a significant association between a non-innocent murmur and abnormal findings on physical examination and echocardiography. There was also a significant association between important murmurs and age less than one year with ultrasound findings. Discussion: Cardiac murmurs in children are a frequent reason for referral. Most murmurs in children are benign. Clinical features allow for differentiation between innocent and pathological murmurs. As described in previous studies, abnormalities found on physical examination and younger ages are warning signs that require a more detailed evaluation.

Evaluation of Children With Heart Murmurs

Cardiac murmurs can be a source of anxiety for both physicians and parents until serious cardiac disorders are excluded. The innocent cardiac murmur is still the most common finding in healthy children and can usually be diagnosed through obtaining a complete history and performing a complete physical examination. However, a cardiac murmur may be the first sign of a structural cardiac disease and should not be ignored. Referral to a pediatric cardiologist for further evaluation is required when murmur assessment is not clear and diagnostic uncertainty is present. Educating and reassuring parents remains an important aspect of this evaluation. This article discusses features of innocent and pathological murmurs and provides an approach to cardiac murmurs in children.

Evaluation of a Newborn With a Murmur

The incidence of murmurs in children has been reported to be as high as 90% (Frommelt, 2004). However, the prevalence of structural heart disease is only 8 to 10 per 1000 live births, with approximately one quarter of these children having critical congenital heart disease (CHD), defined as requiring surgical or catheter intervention in the first year of life (Mahle et al., 2009). Therefore it is the job of the primary care provider to identify the newborns who require investigation of their murmur.

COLOR SPECTROGRAPHIC PHONOCARDIOGRAPHY FOR THE DETECTION AND CHARACTERIZATION OF PEDIATRIC HEART MURMURS: A CASE SERIES

Although auscultation of the heart remains central in the detection of abnormal heart sounds and murmurs that are frequently indicative of serious cardiac pathology, the application of electronic methods to this end remains rarely used in daily clinical practice. In this report we provide a series of examples showing how the phonocardiogram can be analyzed quantitatively using color spectrographic techniques and discuss how such methods may be of future value for noninvasive cardiac monitoring. Using a sound recording system, we recorded the heart sounds and data acquisition using the program Gold Wave ( http://www.goldwave.com ) to collect data from a high-speed USB interface. Sample color spectrogram analysis of the obtained signals was performed using custom software written in MATLAB. Data was collected from a number of infants and adults with cardiac structural disease as well as from some normal individuals. Our data is presented as a series of 13 cases. We expect the application of spectrographic techniques to phonocardiography to grow substantially as ongoing research and clinical experience demonstrates its utility in various settings. Our evaluation of a simple, low-cost phonocardiographic recording and analysis system to assist in determining the characteristic features of heart murmurs shows promise in helping distinguish normal heart sounds, innocent systolic murmurs and pathological murmurs in children. It expected to be useful in other clinical settings as well.

The Utility of Outpatient Echocardiography for Evaluation of Asymptomatic Murmurs in Children

The purpose of this study is to review sedated outpatient echocardiograms performed to evaluate asymptomatic murmurs in children between the ages of 1 month and 4 years and describe outcomes of tests done to determine if utility varies among age of study and referral type (primary care physician vs. pediatric cardiologist.) We aim to describe the yield in a contemporary cohort which has increased availability and quality of diagnostic aids such as fetal ultrasound, newborn pulse oximetry, and neonatal echocardiography. Retrospective cohort study. Cincinnati Children's Hospital Medical Center: Outpatient Echocardiography Laboratory. Children between 1 month and 4 years of age with asymptomatic murmurs who are referred for outpatient echocardiogram for evaluation of murmur. Primary diagnosis of echocardiography studies, classified into severity score. Results. Four hundred sixty-two sedated echocardiograms were studied. Six (1%) echocardiograms showed severe pathology, and no severe pathology was shown in the echocardiograms ordered at the age of over 6 months old. The yield of studies decreased as age increased. The incidence of abnormal pathology was higher among tests ordered by cardiologists, across all severity levels (P < .0001). Among echocardiograms ordered for children over 1 year of age with an asymptomatic murmur, there was no severe and little moderate disease. Cardiac disease is significantly less likely when echocardiograms are ordered without referral to a pediatric cardiologist. The workup for asymptomatic murmurs does not require an echocardiogram, and these results may aid clinicians when deciding whether evaluation of a child should include this study.

Intelligent Identification of Childhood Musical Murmurs

Heart murmurs are often the first signs of heart valvular disorders. However, most heart murmurs detected in children are innocent musical murmurs (also called Still′s murmurs), which should be distinguished from other murmur types that are mostly pathological, such as regurgitant, obstructive, and flow murmurs. In order to reduce both unnecessary healthcare expenditures and parental anxiety, this study aims to develop algorithms for intelligently identifying musical murmurs in children. Discrete wavelet transform was applied to phonocardiographic signals to extract features. Singular value decomposition was applied on the matrix derived from continuous wavelet transform to extract extra features. The sequential forward feature selection algorithm was then utilized to select significant features. Musical murmurs were subsequently differentiated via a classification procedure consisting of three classification techniques: discriminant analysis, support vector machine, and artificial neural network. The results of 89.02% sensitivity, 84.76% specificity and 87.36% classification accuracy were achieved.