Auscultation of Pediatric Heart

Murmurs

Rdiger Schultz, MD, PhD

Pediatrician
Ilembula Hospital
Normal heart sounds during a single
cardiac cycle
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S1 S2 S1

S1-S2 Sytole; S2-S1 Diastole

S1= Opening of mitral and tricuspidal valve
S2= Concomitant closure of Aortic and Pulmonal valve
During inspiration S2 is splitted, the aortic valve closes earlier then
the pulmonal valve. During expiration the valves close concomitantly
and no splitting of S2 can be observed.
 Not every murmur points to a defect
So called physiologic murmurs consist of a melodic, vibrational and
smooth component and have usually their origin in turbulences of
blood flow or are due to vibration of vessel walls. They are usually
proto-mesosystolic.

The second heart sound should not be permanently splitted.

Physiological murmurs do usually not appear during the diastolic

phase.
Examples of physiological murmurs
Stills murmur:
- Vibratory, musical sound, sometimes high pitched and appears during the proto-
mesosystolicum. The best auscultation point is the mitral-valve area and the murmur
may disappear when the child is raised into the upright position.
Physiologic ejection sounds:
- Smooth, blowing sound during early systolic phase. Is enhaced when the child is in
supine position.
Venous murmur:
- Is the only physiologic murmur, which can be best heared during the diastolic phase.
Best point for auscultation is the right supraclavicular region. The murmur is due to
venal blood-flow into the upper caval vein, sometimes beautifully emerges as the call
of a seagull.
 Pathologic Murmurs
Persistant ductus arteriosus (PDA)
-holosystolic, reaching into the diastole, machinery murmur.
-PM left side of upper sternum, pulmonal auscultation point

Ventricle septum defect (VSD)

-holosystolic, harsh, blowing sound
-PM apex area, mitral valve auscultation point
 Pathologic murmurs
Atrial septum defect (ASD)
-weak systolic murmur, PM pulmonal auscultation area
-S2 is permanently splitted which can be best heard at the second
intercostal space at the left sternal margin.

Aortic coarctation (CoA)

-Systolic, smooth murmur, PM at the inferior angle of left scapula
-The systolic sound may be undetactable if the patient has left
heart insufficiency. Measuring of the blood pressure of all four
extremities differs the coarctation from innocent heart murmurs
 Pathologic murmurs
Aortic stenosis (AS)
-systolic, harsh murmur with a crescendo and decrescendo in
intensity. PM right upper sternal margin, propagated to the neck

Pulmonal stenosis (PS)

-holosystolic, harsh murmur, PM pulmonal auscultation area
propagated to the back
Auscultation points
 How to make records on murmurs
Grade of sound (loudness and propagation) usually grade I-V
-Grade I-II: low intensity, grade I is barely auscultable
-Grade II-III: clearly auscultable, moderate intensity
-Grade III-IV: loud murmurs, grade IV is also palpable
-Grade V: loud murmur, palpable vibration
 Localisation during the heart cycle
and quality of murmurs
Systole or diastole, holosystolic

Quality of sound: harsh, soft, blowing, increasing or decreasing during

the end of systole or diastole (crescendo-decrescendo)
Appearance of additional components before or after the murmur,
like opening clicks or snaps
Area where best heard (punctum
maximum)
Describe the site for best and clearest ausculation:
-pulmonal area
-aortic area
-axilla or apex
-intercostal space on left or right margin of sternum
-back
-propagations
 Example
-VSD:
Holosystolic, harsh and blowing, grade III murmur, p.m. left parasternal
region, 4. ICS, no propagation. S2 not permanently divided

-PDA:
Holosystolic and diastolic, mashinery murmur, grade II-III, p.m.
pulmonal region, no propagation,
(errecting of the child doesent change grade and quality of the
murmur).
Thank you for listening