Differential diagnosis of heart murmurs in children.

When a heart murmur turns up on routine examination of an otherwise health child, a thorough cardiovascular evaluation should be carried out according to the guidelines presented in the first two articles in this series (June, page 235, and July, page 151). The information gained by inspection, palpation, and auscultation is then coordinated and analyzed to arrive at the most likely diagnosis, as described in this concluding presentation.

Evaluation of heart sounds and murmurs in children.

Auscultation is the core of pediatric cardiovascular evaluation and should be performed according to a routine. The four heart sounds should be sought in order at their usual locations, with particular attention to the second sound because of its important diagnostic role in congenital cyanotic heart disease. The next sounds to listen for are clicks, which can be systolic, pulmonary, aortic, or midsystolic. Finally, murmurs should be sought in systole and then diastole. Besides being identified as systolic, diastolic, or continuous, murmurs should be characterized according to their relationship with the first and second heart sounds, intensity, frequency, and maximum location and radiation.

Syndrome of single ventricle without pulmonary stenosis but with left atrioventricular valve atresia and interatrial obstruction. Palliative management with simultaneous atrial septostomy and pulmonary artery banding.

Case histories of four infants with single ventricle and left atrioventricular (AV) valve atresia, with interatrial obstruction but without pulmonic stenosis, are presented. Relief of interatrial obstruction by surgical or balloon atrial septostomy resulted in a marked fall in the left atrial pressure and the pulmonary artery mean pressure and resistance as well as a marked increase in the left-to-right interatrial shunt, pulmonary blood flow, and systemic arterial oxygen saturation. Because of this predictable fall in pulmonary vascular resistance, concomitant pulmonary artery banding was performed in each case with good results. There are only a few previously reported cases of single ventricle with left AV valve atresia. Interatrial obstruction is quite common in this lesion. The concept that relief of interatrial obstruction produces a rapid and predictable fall in the pulmonary vascular resistance and that concomitant pulmonary artery banding is necessary in these infants with complex congenital heart disease is emphasized.

Use of contrast echocardiography in diagnosis of anomalous connection of right superior vena cava to left atrium.

A 4-month-old infant with cyanosis but without other abnormal cardiac findings is presented in whom the diagnosis of anomalous systemic venous connection to the left atrium was made by contrast echocardiography. The diagnosis was later confirmed by cardiac catheterisation and selective cineangiography. When saline was injected into a vein on the dorsum of each hand while echocardiographically recording the cardiac structures, the left atrium, left ventricle, and aorta were opacified without visualisation of the right ventricle. Similar study with injection into the right foot produced opacification of the right ventricle without visualisation of the left-sided structures. These data suggested normal drainage of the inferior vena cava with anomalous connection of the superior vena cava to the left atrium. A review of the previously reported cases of anomalous connection of the right superior vena cava to the left atrium is presented together with the possible embryological origin of this anomaly.