1. Murmurs
Dr. Kalpana Malla
MBBS MD (Pediatrics)
Manipal Teaching Hospital
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2. Classification of CVS anomaly
1. Structural heart defects-cyanotic, acyanotic
2. Functional heart defects – cong cardiac arrythmias
3. Positional heart defects - dextrocardia

3. Murmurs
• Turbulence in blood flow at or near valve -
flow murmur
• An abnormal communication within heart –
shunt murmur
• Heart murmurs may be present without any
heart disease

4. Types
1. Innocent or functional
2. Pathological or organic

5. INNOCENT MURMURS:
Also known as flow, benign, non pathologic,
functional, inorganic physiologic
Occur in up to - 77% of neonates
- 66% of children
- 90% with exercise

6. What are Innocent Murmurs?
- Due to physiological turbulence of blood within
normal anatomical heart
- No structural cardiac Ds
- No hemodynamic abnormalities
- Become prominent – fever, anxiety, anemia,
infections

7. Character of IM
• Systolic soft grade 2 ** exception venous hum
– continuous murmur
• No thrill
• Intensity variable – change with posture
• Normal pulse
• Normal S2
• Normal CXR & ECG

8. Pathologic murmurs
• Associated with structural abnormalities of CVS
• Characteristics:
• Grade 3 or louder
• Thrill +
• Pansystolic ,diastolic
• Abnormal pulse
• Cardiac symptoms
• Abnormal ECG,CXR

9. Systolic Murmurs
1. Holosystolic /Pansystolic
- MR
- TR
- VSD

10. Systolic Murmurs
2. Ejection systolic (Midsystolic)
- Innocent M
- Flow M – all flow M in VSD,ASD,PDA
- Aortic valve sclerosis
- Aortic outflow obstruction - Aortic stenosis
3. Late systolic M
- MV prolapse
- TV prolapse

11. Diastolic murmurs
• Early diastolic M
- Aortic Regurgitation
- Pulmonary R
• Mid – Diastolic M
– MS
– TS
– Artial myxoma
– ↑ flow across AV valve
– Austin Flint M
– Carey- Coombs M

12. Diastolic murmurs
• Late Diastolic M ( Presystolic M)
- MS
- TS

13. Continuous Murmurs
– PDA
– Aorticopulmonary window
– Arteriovenous fistulas
– Venous hum

14. Nada’s criteria:
MAJOR MINOR
1.Systolic murmur 1.Systolic murmur<3
grade>3
2.Diastolic murmur 2.Abnormal S2
3.Cyanosis 3.Abnormal ECG
4.CCF 4.Abnormal x-ray
5.Abnormal BP

15. Diagnosis:
• Presence of 1 major
OR 2 minor criteria
• Nada’s criteria for presence of heart disease

16. Innocent Murmurs of Childhood
1. Vibratory Still′s murmur
2. Pulmonary flow murmur
3. Physiological pulmonary flow murmur of
neonate
4. Carotid bruit
5. Venous hum
6. Apical murmur

17. Vibratory Still’s Murmur
Most common innocent murmur of
childhood
Age — 2 to 6 years, rare in teens
Etiology—unknown, may be associated
with LV ejection

18. Still’s Murmur
Location—max at LLSB, LMSB
Character—vibratory, groaning, musical
Radiation— apex,
Timing—mid-systole
Intensity—grade I-II
Pitch—mid to low

19. Still’s Murmur ……
Variation—
Loudest - supine, after exercise, with
fever, anemia, or excitement
Disappears or localizes to LLSB when upright
Normal ECG

20. 2. Pulmonary Systolic Murmur:
Age — common 8-14 years
Etiology—normal ejection vibrations
,turbulence through PV
Intensity— mid systolic grade I-III
Location - ULSB
Pitch—mid to high-pitched
Character—soft, blowing, somewhat
grating, diamond-shaped

21. Pulmonary Systolic Murmur
Variation—louder when supine, fever, -
exercise, anemia
D/D
ASD
PS
Sub AS
ToF

22. Physiological Pulmonary flow
murmur of neonate
Age —newborns. May last 3 – 6 months
Etiology— turbulence and relative
obstruction at PA bifurcation due to acute
angle at birth

23. Physiological Pulmonary flow murmur
of neonate
Location—LUSB
Radiation—LMSB, bilateral axillae, mid-
back
Timing—early to mid-systole

24. Physiologic PPS
Intensity—grade I-II
Pitch—high-pitched
Character—blowing, not harsh, diamond-
shaped
Variation—none

25. 4. Carotid Bruit
• Bruit is French for “noise”
• Age range—children and young adults
• Etiology— turbulence at take off of carotid
or brachiocephalic vessels

26. Carotid Bruit (Characteristics):
Location—neck - suprasternal
notch, supraclavicular areas
Radiation—carotids, below clavicles
Timing—early to mid-systole (grade I-III)
Character—may be slightly harsh
Arise in carotid or subclavian arteries

27. Carotid Bruit
Variation—decreased intensity with
hyperextension of shoulders; louder with
anxiety, anemia,
D/D
Supravalvar or valvar AS
CoA
Bicuspid AoV

28. 5. Venous Hum:
Second most common innocent murmur
Etiology—turbulence in jugular and subclavian
venous return meeting in SVC
Age - pre-school
Adololescents - can be + w/ increased blood
flow states e.g. anemia, pregnancy,
thyrotoxicosis

29. Venous Hum
Location—anterior neck to mid-infraclavicular
area, R side > L side
Radiation—may go to LMSB
Intensity—grade I-III
Pitch—mid to low
Character— continuous ,soft, whispering,
roaring, or blowing

30. Venous Hum
Variation—
Disappears - supine position,
- with gentle manual compression
of jugular vein
- with head turn AWAY from the side

31. Thank you
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