Functional flow murmur

practical knowledge

1. Functional Flow Murmurs Saurabh Bhardwaj MD , Cardiology Trainee, National Heart Institute, New Delhi

2. Introduction Murmurs that occur in the absence of either morphologic or physiologic abnormalities of the heart or circulation have been called normal, innocent, functional, physiologic, or benign . Heard in 50% or more of children, particularly at around 3 or 4 years of age. In general, these are low in intensity , low in frequency and not harsh in quality. Mostly are systolic ejection in timing, with the exception of the venous hum. Not associated with abnormalities in the palpation and are associated with normal heart sounds. Vibratory midsystolic murmurs (SM) from four healthy children. The murmurs are pure frequency, relatively brief, and maximal along the lower left sternal border (LSB). The last of the four murmurs was from a 5-year-old febrile girl. After defervescence , the murmur decreased in loudness and duration.

3. A. Systolic 1. The vibratory systolic murmur of Still 2. The pulmonary artery systolic murmur 3. The branch pulmonary artery systolic murmur 4. The supraclavicular systolic murmur 5. The systolic mammary souffle 6. The aortic sclerotic systolic murmur 7. The cardiorespiratory systolic murmur B . Continuous 1. The venous hum 2. The continuous mammary souffle 3. The cephalic continuous murmur Classification

4. Still's Murmur Commonest and has many descriptions, including innocent, vibratory, functional, normal , and physiologic murmur. It is a systolic ejection murmur heard loudest somewhere between the left lower sternal border and the apex. Quality-vibratory , musical, or twanging string quality, its usual intensity is grade I to III/VI Low-frequency. Heard best with the patient supine. Varies significantly with respiration, becoming softer and less vibratory during inspiration . As with all innocent murmurs, the electrocardiogram and chest radiograph are normal. Suggested mechanisms include relatively smaller aortic size resulting in increased velocity of blood through the aorta during ejection, left ventricular false tendons, exaggerated vibrations with ventricular contraction , and increased cardiac output.

5. Pulmonary Flow Murmur of Childhood Commonly detected in thin-chested adolescents between 8 and 14 years of age, it is heard maximally over the pulmonary area. Although it resembles the ejection murmur of pulmonary stenosis, it is not particularly harsh in quality, and not accompanied by a click or thrill. Its intensity is 1 to 3/6, and the second heart sound should have normal splitting with the P2 component sounding normal. This murmur is frequently heard in patients who have increased cardiac output from fever, anemia, or pregnancy. (If this murmur is heard in the presence of fever, and is not present when afebrile , it may not require any further evaluation .) If the murmur of pulmonary flow is present in a patient who is not in an increased output state, lesions of increased pulmonary flow, such as atrial septal defects, should be considered . A, Phonocardiocardiogram recorded from within the pulmonary trunk (PT). B, Echocardiogram (apical view) from a 12-year-old boy with a left ventricular (LV) false tendon that was an incidental finding.

6. Pulmonary Flow Murmur of Infancy Also referred to as a peripheral pulmonary flow (peripheral pulmonary stenosis) murmur, this murmur is commonly heard during the newborn period and early infancy, particularly in premature infants. Ejection murmur that radiates from the left upper sternal border over the lung fields to both axillae and the back. Theories of its origin include the relatively small size of the branch pulmonary arteries immediately after birth, as well as their angle of the takeoff from the main pulmonary artery during the newborn period. It usually disappears by 6 months of age. Pulmonary artery systolic murmurs (SM) recorded from the second left intercostal space of two healthy children aged 8 and 11 years. The murmurs are brief, midsystolic , and mixed frequency.

7. Venous Hum The only innocent murmur that is not systolic ejection in its timing. Low frequency and truly incessant when the patient is upright. Generally , some variation in pitch and intensity occur with respiratory and cardiac cycles. This murmur will cease with maneuvers that occlude the neck veins, either by direct compression using a thumb, or by turning the patient's head to look over the contralateral shoulder. Gravity driven-this murmur should also completely disappear with the patient flat in a supine position. Continuous venous hum in a healthy 24-year-old woman. The diastolic component of the hum is louder (paired arrows ). Digital pressure on the right internal jugular vein (vertical arrow) abolished the murmur.

8. Thank You ! Natural forces within us are the true healers of disease . — Hippocrates