Naile TUFAN PEKKÜÇÜKŞEN, Tuğba TAŞ, Sadi TÜRKAY

Investigation of Pediatric Innocent Murmur with Echocardiography

Abstract Introduction: Innocent murmurs are common in childhood. Usually, they are heard without any structural and physiological abnormalities. The murmur is usually weak and short. But even if it is thought to be innocent, echocardiography (ECHO) is occasionally requested by primary doctor or families. The aim of this study is evaluation of childhood innocent murmur with ECHO and possible minor findings with normal clinical status. Method: This is a descriptive - retrospective chart review. We reviewed the charts of children and adolescents who were referred with asymptomatic murmur to Pediatric cardiology clinic at Fatih University Hospital between 01/ 2010 – 12/2011. We excluded cases who are found with any type of congenital/acquired cardiac diseases. Due to the nature of this study, we only included first to third degrees of murmurs. All participants are analyzed based on demographic, clinical, and ECHO finding data. Results: We reviewed 610 charts. 115 cases (18%) were excluded. 495 cases (82%) were included in the study. 209 (42.2%) of them were female and 286 (57.7%) were male. Age range was between 1 and 202 months (52,2 ± 41,9), height was between 50 and 175cm (102,2 ± 28,8) and body weight was between 3.70 and 97kgs (18,8 ± 12,89). Minimal Tricuspid valve regurgitation (TVR) was seen in 200 children (40.4%) and minimal TVR+ physiological Mitral valve regurgitation (MVR) was seen in 65 children (11.6%). Patent foramen ovale (PFO) was seen in 306 children (54,8%). Left ventricular (LV) muscular band (false tendon) was seen in 171 children (30,6%). Minimal TVR + physiological MVR+ LV muscular band (false tendon) was seen in 26 children (4,7%), trivial arteria valve regurgitation (AVR) was seen in 7 children (1,4%), and minimal TVR + minimal pulmonary regurgitation (PR) was seen in 11 cases (2%). Discussion: Even though the nature of murmur in physical exam supports the diagnosis of innocent murmur, evaluation with ECHO is commonly requested by families and physicians. In our study we excluded 18% of cases due to the presence of primary cardiac diseases. Included cases also exhibited some cardiac findings but none of those cause any shown cardiac dysfunction in near future. We advise innocent murmur group to be followed by primary physician unless they have any cardiac symptoms.

Keywords:

innocent murmur, echocardiography, pediatric,

PDF

___

1. Frank JE, Jacobe KM. Evaluation and management of heart murmurs in children. Am Fam Physician. 2011;84(7):793-800.
2. Pelech AN. The cardiac murmur. When to refer? Pediatr Clin North Am. 1998;45(1):107-22.
3. Martins P, Dinis A, Canha J, Ramalheiro G, Castela E. Innocent heart murmurs. Rev Port Cardiol. 2008;27(6):815-31.
4. Castle RF. Clinical recognition of innocent cardiac murmurs in children. JAMA. 1961;177:1-5.
5. Sachdeva R, Douglas PS, Kelleman MS, McCracken CE, Lopez L, Stern KW, et al. Effect of Release of the First Pediatric Appropriate Use Criteria on Transthoracic Echocardiogram Ordering Practice. Am J Cardiol. 2016;118(10):1545-51.
6. Oran B, Bodur AS, Arslan D, Cimen D, Guvenc O. Normal M mode values in healthy Turkish children. Turk J Med Sci. 2014;44(5):756-63.
7. Pettersen MD, Du W, Skeens ME, Humes RA. Regression equations for calculation of z scores of cardiac structures in a large cohort of healthy infants, children, and adolescents: an echocardiographic study. J Am Soc Echocardiogr. 2008;21(8):922-34.
8. Kim HJ, Yoon JH, Lee EJ, Oh JH, Lee JY, Lee SJ, et al. Normal left ventricular torsion mechanics in healthy children: age related changes of torsion parameters are closely related to changes in heart rate. Korean Circ J. 2015;45(2):131-40.
9. Dallaire F, Slorach C, Hui W, Sarkola T, Friedberg MK, Bradley TJ, et al. Reference values for pulse wave Doppler and tissue Doppler imaging in pediatric echocardiography. Circ Cardiovasc Imaging. 2015;8(2):e002167.
10. Fogel DH. The innocent systolic murmur in children: a clinical study of its incidence and characteristics. Am Heart J. 1960;59:844-55.
11. Castellotti DS, Makssoudian A, Mendes MC, Fisberg M. Heart murmur in pediatrics: innocent or pathologic? Rev Paul Med. 1992;110(1):29-33.
12. Uner A, Dogan M, Bay A, Cakin C, Kaya A, Sal E. The ratio of congenital heart disease and innocent murmur in children in Van city, the Eastern Turkey. Anadolu Kardiyol Derg. 2009;9(1):29-34.
13. Kozan M MT, Saylam G, Dundar B, Hudaoglu S, Akcoral A Cocukluk cagindaki Masum Ufurumlu Olgularin Laboratuar ve Ekokardiyografik Olarak Degerlendirilmesi. . Dokuz Eylul Tip Fakultesi Dergisi. 1998;12:249-59.
14. Altıntaş G AE TA, Dikmengil M. Adana ili ilkokul çocuklarında kalp üfürümleri taraması. Ç Ü Tıp Fakültesi Dergisi. 1988;3:211-4.
15. Aygün D KS AS, Yaşar F, Türkbay D. İlkokul çocuklarında kalp üfürümlerinin sıklığı ve önemi. Türkiye Klinikleri Pediatri Dergisi 1998.
16. Elevli M Yİ DC. Diyarbakır il merkezinde iki ilkokuldayapılan anemi ve üfürümleri taraması. Dicle Tıp Bülteni. 1991:145-53.
17. Koç A KM AA, Kılınç M İlköğretim çağı çocuklarında kalp üfürümleriprevelans çalışması. Türk Pediatri Arşivi 1997;32:28-33.
18. Yıldırım MS ME KY. Diyarbakr ili belediye hudutları dahilinde 7-18 yaşları arasındaki ilk ve orta dereceli okul öğrencilerinde doğumsal kalp hastalığı oranı. Türk Kardiyoloji Derneği Arşivi. 1986;14:21.
19. Advani N, Menahem S, Wilkinson JL. The diagnosis of innocent murmurs in childhood. Cardiol Young. 2000;10(4):340-2.
20. Bronzetti G, Corzani A. The Seven "S" Murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila). 2010;49(7):713.
21. Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Beland MJ. Can cardiologists distinguish innocent from pathologic murmurs in neonates? J Pediatr. 2009;154(1):50-4 e1.
22. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Jr., Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(13):e1-142.
23. Smythe JF, Teixeira OH, Vlad P, Demers PP, Feldman W. Initial evaluation of heart murmurs: are laboratory tests necessary? Pediatrics. 1990;86(4):497-500.
24. Mellies U, Hentrich F, Hofelich B, Neudorf U, Schmaltz AA. [The incidental heart sound. Study of clinical diagnostic certainty and possible causes]. Klin Padiatr. 1992;204(5):323-7.
25. Shub C. Echocardiography or auscultation? How to evaluate systolic murmurs. Can Fam Physician. 2003;49:163-7.
26. Van Oort A, Hopman J, De Boo T, Van Der Werf T, Rohmer J, Daniels O. The vibratory innocent heart murmur in schoolchildren: a case-control Doppler echocardiographic study. Pediatr Cardiol. 1994;15(6):275-81.
27. Brenner JI, Baker K, Ringel RE, Berman MA. Echocardiographic evidence of left ventricular bands in infants and children. J Am Coll Cardiol. 1984;3(6):1515-20.
28. Ozme S, Ozkutlu S, Muftuoglu S, Baysal K, Saraclar M, Tuncali T. Left ventricular aberrant bands in children with innocent murmurs. Turk J Pediatr. 1987;29(2):73-9.
29. Kostucki W, Vandenbossche JL, Friart A, Englert M. Pulsed Doppler regurgitant flow patterns of normal valves. Am J Cardiol. 1986;58(3):309-13.
30. Van Dijk AP, Van Oort AM, Daniels O. Right-sided valvular regurgitation in normal children determined by combined colour-coded and continuous-wave Doppler echocardiography. Acta Paediatr. 1994;83(2):200-3.
31. Haney I, Ipp M, Feldman W, McCrindle BW. Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians. Arch Dis Child. 1999;81(5):409-12.
32. Hansen LK, Birkebaek NH, Oxhoj H. Initial evaluation of children with heart murmurs by the non-specialized paediatrician. Eur J Pediatr. 1995;154(1):15-7.