Good afternoon everybody. Thank you for joining us for our cmu lecture this day today. Sorry I'm tablet that one of your physician liaisons and I'm just going to go over a few housekeeping rules before we get started. Um as you know you're all muted so please if you have any questions please put them in the Q. And A. And dr chris d'elia was asking that if you have questions throughout the lecture to go ahead and put those in we'll keep track of them so that we can answer them in the moment just to make sure that um you guys are learning as much as you can and then um please don't forget that at the end of the lecture there will be um an evaluation that pops up. Please fill that out so that we're able to give you see any credits if you don't we're not able to give those to you. So that's very important. If you don't get it at the end of the lecture please make sure you contact myself or your physician liaison and we'll make sure to get the to get that to you. Um Let me get to the next slide real quick. Um We are moving our cmu lectures to Tuesday so um hopefully you will all still be able to attend our lectures. These are our next two lectures for May. We are doing May 10th with dr Black and then we were doing our next cmi on the 17th with dr Irwin on headaches. Um And that will also be a semi so if you are interested please look out for your emails with an update or you can contact your physician liaisons and then here are all of us Maria myself, Amy and our newest member Lauren are here to answer your questions meet any of your needs. Um We also have all of our lecture, our webinars recorded and they are on our med connection page and there it is listed below. And if please make sure you use this link, we have some old links that are still out there that don't go to the right place. So make sure you click this link and if you don't have it then please make sure you contact your physician liaison. Um And we are actually now offering cmI credits for these lectures or cmu lectures. So our last one with Dr Nadarajah from March is up on our website. If you missed it and you want to get credits you can do that on our site or if you have any colleagues who missed today's lecture that will be up in a few weeks um and available for credit as well. So let me go back and introduce our speaker. Dr Castalia. She is a pediatric cardiologist with expertise in pediatric fetal and okay I'm gonna try to say this correctly. Trans vigil echocardiography, echocardiography or ultrasound of the heart in addition to caring for infants and Children as out patients in the clinic she cares for are hospitalized pediatric patients with hearty heart disease or following cardiac surgery and um I'm just going to quickly Ian share and let dr chris D'elia share. Thank you so much. Doctor Crystal you for joining us. Great. Thanks so much for having me today. Yeah, no problem. See share screen here. Um So as you mentioned, I'm one of the pediatric cardiologists at UCSF. And my specialty from the clinical side is within echocardiography, but I also actually run our pediatric cardiology fellowship program now I stepped into that role about six months ago. Um And so I meet with our trainees very frequently and I think that's probably for many of you. Um sometimes the first point of contact with our group. So I think our fellows are an excellent group and kind of an extension of our division. Um So for today I'll be talking about murmurs, which was one of the requests from people to hear about. Um I will give a quick disclaimer that um I included a little more than just murmurs and kind of the total ostentation of the heart just because this can be something that can be incredibly helpful um from a pediatric standpoint in screening patients for forms of congenital heart disease. Um I have no financial disclosures. Um I did steal a lot of this lecture from some of our fellow um power points that they give, they do a lot of teaching with our pediatric residents. Um And most recently an Shay was the one who did a lot of edits on this for me. Um so rather than reinvent the wheel, I thought I'd do something that already works. Um and please just like Tabatha said I'm happy to take questions as I go through this talk, I'd much rather answer something um in the moment if there's something that doesn't quite make sense or if it needs a little clarification, so please feel free to type into the Q. And A. Um So our objectives for today are really recognizing that consultation is just one component of the pediatric cardiac exam. Um and then we'll want you to understand the physiology and path of physiology behind these various sounds, clicks, rubs and murmurs and then you should be able to identify the common murmurs and the primary care setting as well as recognize indications for cardiology referral. So basically if it doesn't fit any of those common innocent things, it would be something to refer for us to evaluate. So just briefly kind of touching on key historical features which I'm sure everyone in this group is already aware of? Um you know, so we think about birth history. Do they have prenatal imaging? Do they need resuscitation? Was there some sort of nursery or nicu course that's out of the standard? Um and then everyone gets a pulse ox test. Now this has been such a huge change in terms of being able to pick up that's sort of critical congenital heart disease early on in life. This started around the time of 1000 residency. And so I think I've been very fortunate to be on this side of that. And then feeding history is incredibly important. Feeding for babies is exercise. And that gives us a very good sense of whether they can augment their cardiac output. Family history can also be very important, especially with um specific disorders like aortic valve disease can very much run in families. And then you see here is a nice example of a growth curve that is very sub optimal. Um and so this would definitely be a patient that congenital heart disease would be on your mind in terms of why there, you know, they were fine here. They seem to be growing a bit here, but then really fell off the curve. And then general physical exam sort of outside of the heart, you know, looking at vital signs, getting foreland blood pressure's thinking of pulses paradoxes in certain populations. Um dysmorphic features that are present can be helpful in terms of thinking of congenital heart disease that goes along with various syndromes, which is again out of the scope of this talk and then just their general appearance. Are they anxious? Are they cyanotic? Are they breathing comfortably but fast? All of these things can help us sort out whether there's some cardiac issue. Um and then in terms of the cardiac exam itself, we think about perfusion pulses very much liver. Um I tell all of our pediatric residents and fellows that liver, liver, liver is huge in part of our exam, um examining the lungs and then, um, in terms of the heart, we think of inspection palpitation and then finally ostentation. So that'll be the bulk of the talk for here. Um, This is actually just a nice diagram. All these slides will be provided for you afterwards to to kind of keep us reference if that's helpful of sort of outlining on the sternum where these heart structures lie. And so if we keep this sort of geographic map in mind that can actually help understand what you might be hearing at various parts of the pericardium of the accordion. Now again, that's it. If it's a relatively normal segmental heart, this definitely doesn't apply if the patient has dextre cardia or if they have some of the more complex lesions. And then what we think of in terms of kind of getting into the heart sounds is what is the cardiac cycle? And so I think people have likely seen figures diagrams before. I realized for some it might not have been since medical school. Um, so I'll walk this through briefly. But the two main lines to sort or three rather lines to pay attention to the most for this talk specifically would be the aortic pressure up here, the atrial pressure, which is here in the dotted line and then the ventricular pressure, which is here in this red line. And so what happens is I'll go through this in a couple of slides. Um But this website listed down here is a nice one because it actually walks through it as a video for for you to um And then this is sort of what is mechanically happening within the heart during each of those phases. So the next several slides will kind of walk through each of those steps for you. Um So initially there's going to be ventricular filling sort of the beginning of diastolic. So on the wiggles diagram here you can see that we have this is a volumetric contraction. I mean relaxation. And then this line here is one that aortic um is when the ap valve opens here. Because you can see this atrial um The ventricular pressure now is below the atrial pressure. And so the atria is higher than going to push that valve open. And so this sort of blue period here is that early diastolic filling. The next portion is something that we call dia esta sis where that early part has finished. And there's just this continued flow during diastolic. And then the third portion of diastolic is actually what we call atrial sisterly or the atrial kick. And so at the very end the atria actually squeeze very briefly and add a little extra volume into that ventricle. And then you have this next line here where that every valve closes. And then there's this very brief period where the ventricle has already started to squeeze. And so you see this red line here the atrial pressure is going up but it has not yet overcome the aortic pressure. And then this time this next part here oop I've frozen. It's actually supposed to be this whole thing. Um But this is actually sisterly. So now that ventricular pressure has overcome the aortic pressure, aortic valve opens and the ventricle ejects blood very rapidly. And then you have the aortic valve closes as that aortic pressure is now above the ventricular pressure. And then you have this brief period of ice, a volumetric relaxation where again the ventricular pressure is still higher than the atrial pressure. And so that every valve is still closed. And so thinking of this, this can actually help us understand the heart sounds right? And so looking at this diagram here we have The valve closes. That's what creates s. one. And then when that aortic valve for semi lunar valves close, that's what creates us too. And so as you know, it can be very challenging in babies. The very fast heart rates to get a sense even just of the S. One and S. Two initially and then starting to listen for the areas in between the heart sounds. Um So again we think of S. One and S. Two. And so thinking of the love dub, dub dub this one is that love as to is the dub. And so you have this shorter diastolic period. And then I started shorter systolic period and then diastolic is longer. And again thinking of that diagram of where do we hear sounds from different valves? We follow the flow of blood and where they're at on the accordion. And so this is kind of thinking of the you know as we all learned well back in medical school um the sort of areas for various valves and reasonably normal segmental heart. So aortic valve would be here with flow going up towards that right upper sternal border, pulmonary flow is going up towards that left upper sternal border. And then you have the mitral valve. You have flow coming down towards the apex of the heart. And then the trick busted valve flow is coming into the tri custard valve also sort of left lower sternal border. But when we think of trick husband record it's actually going backwards and that's actually directed towards the back And so really hearing track has been triggered is incredibly rare unless the valve is that normal. Such as in Epstein's when it's actually pointing towards the front of the chest which I'll get into a little bit of that. So I'll go through all of these the normal heart sounds as well as abnormal heart sounds. And so again s one is the love closure of the A. V valves which are typically the mitral entry husband valves is actually her best at the apex of the heart using the bell of the stethoscope and then as one can be louder or softer depending on these various aspects. So depending on where the mitral valve position is the rate of mitral valve closure and mobility of mitral valve. So if it's very stiff as one might be louder because you hear the sort of stiff leaflets hitting each other And then thinking of us to there's a lot more variation in S. two. so this is when the aortic and pulmonary valves close, this is her best for the diaphragm And then the a. two intensity can be affected by or Dick pressure. So if this patient has systemic hypertension that might sound louder because it's just closing harder with that high pressure. If the order is close to the chest wall this might actually sound louder. So for example if a patient who has transposition of the great arteries, you might hear they order a lot louder um and then the size of the aortic root. So if it's very large that will also sound louder and sort of echoes within that large ascending aorta and then again the degree of opposition of the leaflets and their mobility. So a very thick sort of cyanotic aortic valve might be a harsher closure than loose floppy leaflets that aren't as loud and similarly within the chromatic dolls. The P. A pressure can make it sound loud. So classically with pulmonary hypertension, we think of a loud P two component. Um This is super common. So in babies who are freshly born, all babies pretty much still have that high P. A pressure which is very normal. So high PVR and hypia pressure. When you listen to babies that first day they are born in the first few hours, they all have a pretty loud sounding s to um I won't even pretend to split the S. Two in a normal way at that age just because they have such fast heart rates. But if you kinda listen that first day and then start listening the next day and the next day and the next day it actually gets a little bit softer. It's kind of fun to hear that progression. And then similarly the size of the pulmonary artery. If you have a dilated pulmonary artery for whatever reason, under the sun, it might sound louder and similarly depending on what the valve leaflets morphology is. Mm hmm. Um This is one aspect that I think is super cool because I feel like once I was able to hear this um it's really fun. And so we want to listen for the physiologic splitting of this too. And so this is actually her best sort of the left, mid left, upper sternal border because that's right over the it's sort of right at the base of the heart and so that's where the valves are right underneath you. And so as you know, it typically splits with inspiration. And so as we breathe in our diaphragm goes down, we get more negative inter thoracic pressure, increased venous return to the right side of the heart. And so it actually takes longer for that pulmonary valve to close. Um and so what we see is when a patient takes a breath out, you have this sort of very minimally split A. Two and P. Two. It's is typically so split that we would say it's closed. You can't really hear the difference in that timing with your ear, but then patient takes a breath in and they get this very slight splitting of the S. Two and then they take a breath out again and you hear that close. And so that's what we're listening for. If we have a kid, for example who comes in who might have an asd and so we would we would sit and listen to that. Um This is definitely challenging and smaller kids I think sort of toddler school aged kids definitely sort of middle school kids are great to hear it. It's usually like those middle school boys who have like thin chest are cooperative, It's quiet exam room. Those can really be the best example of this. Um and it's typical that if you can hear a nice splitting of the S. two that's a very very reassuring sign. Things that can make that wider would be things that impact sort of filling up the right side or timing and so for example, if a child has a right bundle branch block, their RV actually squeezes a bit later than the aortic valve. And so even though there is a change in how much volume there is on the right side with breathing, it's still going to be a little bit split all the time. And so kids who say have had A VSD repair and they might have a right bundle branch block that they'll have forever. They might still have that, that splitting that sounds wider than typical. There's some variety in it and that may be very difficult to hear. But for those kids, I would not be surprised that it doesn't close as it should um or if you have a lesion that causes volume overload to the right side because you always have volume overload whether you're breathing in or breathing out. And so those typical defects would be in a SSD and maybe canal which also has an asd as part of it or P A PVR. Um And then finally, if you have a lot of em are the aortic valve might actually close early because the ventricular pressure goes down faster because again, not all that flow is going out the aorta, some of it's actually going backwards again, thinking back to wicker's diagram will get you everywhere. I know it's complicated but it's actually kind of fun if you walk through it and then next instead of a wide split, sometimes you can actually have a narrow split. And so this can also be due to electrical reasons. So something that causes the left side to activate later is going to make it. So the aortic and pulmonary valve actually closed at a more similar time. And so either you slow down the pulmonary valve closure to cause a wide split or you hasten the aortic valve closure. And so with pulmonary hypertension that pulmonary will actually close sooner because the pR pressure overcomes the right ventricular pressure earlier. And so those kids will have a loud P. Two component that is also right on top of the A. Two. And then in patients with aortic valve stenosis, the LV pressure is going to stay high longer because it's taking longer to go through that cyanotic aortic valve. And so the a. two would be um that you two would be later. So it remained closer to the pulmonary battle of closure. And the next, you know, once we think of S. One S. Two we think of S. Three. And so this is actually best heard at the apex or left lower sternal border using the bell. That's because it's as that passive early ventricular filling starts. And so that's why it's sort of down towards the apex because that's the path of blood flow and this is actually just because an increased rate or volume of diastolic filling In kids we think of this as potentially normal. If everything else is normal you don't hear any concerning murmurs, their growth is great, their energy is great. If all you hear is an S. three, that's typically normal things. Do you think of that? We want to kind of rule out in our mind and should be a high cardiac output. So say they have a fever and they may just have faster filling and higher cardiac output going through that ventricle. So you can just hear that little noise or early filling. Patients with significant Emma or tr they have more volume up in the atria that are going through that a. V. Valve into the ventricles, you can hear that again. Um Or if there's significant ventricular dysfunction. So again it kind of depends on the scenario but typically in kids and young adults if everything else is normal we can be reassured that S. Three is fine. Um This is not true for adults. If you hear an S. Three and adults we definitely would need an evaluation there. Alternatively as far is actually abnormal. And so this is what makes a kind of Tennessee Tennessee. So it's coming in right before the next S. One. This is also heard at the apex which can make it a little more difficult to sort out between S. Three and S. Four but this is actually a bit later and it's from the atrial kick. And so it signifies this abrupt end of ventricular filling because the hardest stiff. And so in a nice relaxed heart, most of the filling occurs during early diastolic, So by the time the atria squeezed there's really not a whole lot of blood folks going into that venture paul. But if the heart is very stiff, those patients actually depend on that atrial kick to push more flow into that stiff ventricle. And so that's when you get this late diastolic s for always pathologic and kids or adults. And here's sort of a general differential for you. So thinking of hyper tropes dilated cardiomyopathy, patients have very high filling pressures. Similarly patients with a s will develop high filling pressures over time or if they have an early myocardial infarction. And this is the typically most common reason and adults, which fortunately we don't really have to think about a whole lot with kids. Um The next sort of heart sound we think about would be a rub. Um This I hear all the time when I'm taking care of kids post op. And so this is heard in not everyone, but pretty close to everybody after they've had a cardiac surgery, we've just completely disrupted the pericardium. And so you can hear this nice little scratchy rug. Um And it's basically just caused by inflammation of two layers of the pericardium. And so and other patients might be pericarditis, right? Maybe they had a viral illness recently and they have pericarditis or other inflammatory processes. Um And this has actually heard best with the diaphragm of your stethoscope and it looks like I have a question here so I'm going to take a peek Kentucky and Tennessee? Yes. Um So someone asked if I can clarify Kentucky and Tennessee and so let me actually go back to that real quick. So for so we think of Kentucky is so you think of S. One S. Two S. Three. And so as one is to s. three Kentucky Kentucky Kentucky is sort of the sound it makes and that's kind of how you help your ears here. Is that extra sound closer to the S. Two? Where is it closer to the next test? one vs. Tennis C. So you would have s. one s. 2 s. three Us want us to S. three. So Tennessee Tennessee is a little bit slower. That kind of makes sense. Mhm. I remember a lot of people like we kind of heard that how to remember in medical school and we think of it later on to I don't know that's the best example but yeah um And I should have actually actually let me show a better way to do this. I'm going to annotate real quick um Just to show sort of visually what that would mean. And so if this is S. One it'll draw these out. This is S. Two and then say this is the next set of normal S. One S. Two coming in. So one two, oh that's not gonna do that. Anyway. This is one that's too and this is one and 2. Let me change the color here. So as three would sound right here just after the s. two versus S. Four Would be later in diastolic, just before the next s. one c. of Kentucky Kentucky Tennessee Tennessee. I hope that makes more sense. Um I also have for you at the end of this I have links to some examples of sounds that you can listen to. After the talk. I will say my ability to mimic them verbally is not quite as good as if you're listening to something that's been recorded. So I will go ahead and Nolan. Um So we talked about pericardial rubs. Let me actually clear there's a there we go. Alright so next we think about clicks and snaps and so these can be kind of difficult to parse out. So we'll go through each of them. Um so injection clicks we think of as occurring right after the S. one. So the semi lunar valves aortic or pulmonary valve has just opened. Um And that's when you'll start to hear it and it's heard best of the apex and it's from either stenosis of the aortic or pulmonary valve or a very large aorta or pulmonary artery. This also can be heard in patients who have systemic or pulmonary hypertension. The most common reason you would hear it click is impatient to bicuspid aortic valve if it's over that sort of aortic area or if you hear it close to the pulmonary area that might be a pulmonary valve. It's bicuspid and or rarely and I haven't actually heard this but you can if there's a very large P. D. A. That has now caused P. A. Dilation um I would hope to think we're good at this point of recognizing those pds before there's so much volume low to the P. A. Is that they get dilated. So that would be pretty uncommon. Alternatively in mid systolic click is something that's her best at the apex also. But this is caused by mitral valve prolapse. And so it's not um as you have sisterly and the ventricle squeezes, it's midway through the cycle that that that valve starts to prolapse, it's not right at the beginning. And so again you have to kind of listen closely to tell is that ejection click right at the beginning consistently or is it more in the middle. And then finally an opening snap is actually something that's happening in diastolic. And so ejection clicks are from the summer lunar valves opening snaps are from the A. V. Valves. And so these are also at the apex or maybe left sternal border. So location doesn't quite differentiate them but this is after the S. Two. And so this is if you have a thick and mitral or trick husband valve when they open they may actually make a noise. I think I've heard a like mitral valve opening snap like once that I was able to, so hopefully this is not something that you're hearing a whole bunch. Whereas ejection clicks are super common, especially because by customers, aortic valves are quite common and those are actually pretty fun to hear too. Okay, so now we get to sort of the named part of the talk and go through murmurs. And so what we think of as a murmur is simply a sound. It's just disturbance of laminar flow. Usually it's either increased velocity across an area with a change in either pressure or diameter from one point to another. And so when we think about murmurs it's more than just systolic or diastolic. We think of the timing and duration. We think of what the shape of the sound looks like. And I'll show some of those phonographs we use, we think about the intensity or great where we can hear it, where does it radiate to? What is the pitches, it high or low pitch. This is also sort of frequency for people who are kind of a musical mind. What is the quality? Is it harsh? Is it musical? And then we think of position changers or sort of these provocative maneuvers we can do to increase or decrease the sound of a murmur to help differentiate what it's coming from. So starting first with kind of the basic timing and duration. So again we think of systolic or diastolic is kind of the first group we think of. But there's also this category of continuous where you may hear something throughout the whole cardiac cycle. There's also murmurs that are too far. Oh and those are actually different than continuous because they're kind of more of a kind of change and they actually change a bit where you can hear them. And then we also try to parse it out between. Is it early and sisterly early and diastolic? Or is it hollow? Systolic when it's through the entire system. And then we also look at that shape or configuration. So for example, this would be an example of crescendo. De crescendo rumor. Whereas this would be sort of a plateau member. The crescendo would signify there's there's some change in that pressure going across that valley because you can kind of hear it getting louder and then softer. So for example, the aortic valve opens and then you hear as flow goes across the narrow valve, you might hear it get louder and then softer versus if you have a wide open VSD, you might hear it throughout the entire systolic cycle because the VSD it's not like it's closing, it's always there and the pressure between the RV and LV is relatively stable. Just so you've heard it as well, there's a whole bunch of synonyms for this. And so when we think of ejection murmur um crescendo de crescendo is often the other term that might be used. And you know what? My slide actually didn't do it properly. Um But there's actually there should be a split second between the S. One here and when the murmur starts because again there's that ice, a volumetric contraction period where thinking of that wicker's diagram, the ventricular pressure has not gotten high enough quite yet to overcome the aortic pressure. Similarly on the right side. The RV pressure has not overcome the pressure yet. And so the difference between these two types is really, Does the murmur start immediately with S. one or is there a split second gap? Um That's different than these sort of pan systolic. Which the other terms he would hear whole systolic regurgitation tint. Or S. One coincidence personally I think S. One coincident is the most descriptive because that's what it is. This murmur starts with the S. One, the murmur or sound you're hearing doesn't depend on that semi lunar valve to open. So for example, mitral regurgitation as soon as that left ventricle starts squeezing, you're gonna have blood going back into the left atrium that you can hear as a murmur or with the VSD again that whole is there you don't have to wait for a valve to open for flow to start going across it. Um That's sort of where this regurgitation the term comes from, that was the one I use the most optimum fellowship and residents in his whole systolic. But just be aware that all four of these terms are the same and hollow systolic. I think it is probably the most inappropriate or pans systolic because I think you've all heard like a small um restrictive muscular VSD. Right? Those start at the very right at S. one, but they may stop part way through Sicily because as the ventricle has squeezed in the muscle contracts, that whole just goes away. And so it's still not an ejection murmur. Um But again, that kind of guides you to wear to what it might be from. Alright, I will get off that soapbox. Um so next we think of intensity, how loud is the murmur? And so for systolic murmurs, we grade them from 1-6. Um There's various ways to kind of think about grading them, but this is the one that is present within moss and Adams. So it's someone that I like to use. So grade one is is faint, it's barely audible. This is sort of there's something there or an absence of silence is how you might otherwise describe it. Grade two is where it's soft but easily audible and but it's definitely there, you can hear it for sure. Three we think of as sort of moderately loud. So it's either the same or perhaps a bit louder than the S one and S two heart sounds that can kind of help differentiate there. And then grade four murmurs. That's when there's a palpable thrill present. So unless there's a palpable thrill, it's clearly in the grade 1 to 3 range. Um And I've seen a fair number of people and I do it also of, okay, so it's a grade 2 to 3. It's sort of in there or grade 1 to 2. Um I think that's not completely unreasonable because 123, there is a little heaviness in it, but grade four is clearly there's a palpable thrill. No question. Grade five is even louder. That if you were to take the stethoscope just slightly off the chest, you can still hear it versus Grade six. Your stethoscope is completely off the chest and you can hear that fortunately, Grade four, grade fives and sixes are quite uncommon. Those would definitely be a referral to cardiology as well as anything. That's a Grade four. Grade 3 can be sort of questionable depending on the other qualities of it. And then I'm not going through diastolic murmurs much in this talk, but any diastolic murmur is abnormal and those are graded one through four rather than six, similarly based on loudness. Mhm. Again, thinking of location. Um that's sort of the next thing we would think about. So where do you hear it? So now again, this diagram sort of assumes a relatively normal segmental cardiac anatomy. This would not necessarily be true for some of our patients with hetero taxi or various complex defects but this would get you most of the way. And so again you think of the aortic area here, that's where you might hear aortic stenosis. Or say a child has sickle cell disease and they're very anemic at a period of time. You may hear a little flow murmur across the aortic valve when they're very anemic or if they come in sick with a fever. Um Similarly the harmonic areas here, you might hear some flow members. They're also at times of increased cardiac output or if there's some volume load to the right side. Um And then thinking of the mitral area again that's where we hear this sort of hand systolic or regard distant murmur and then a mid to late diastolic memory you might think of mitral stenosis explodes coming towards you. We actually would hear your list more commonly in patients with a huge VSD. So if they have a very big BSD a lot of left to right shunting their mitral valve is you know can be completely normal but they just have a lot of flow across it. And so that's where you would think of this sort of diastolic murmur of M. S. And sorry if it's if it's just from A VSD that would actually be throughout diagnostically the mid to late is more mitral stenosis because again it takes time for that left atrial pressure to go up to open that that metro valve. And then thinking of the track custom area again. Hearing tr here is actually quite rare because it's more directed towards the back. But A VSD is going to be sort of the most common at this left lower sternal border. And then again thinking of mid to late diastolic perhaps trick husband stenosis because it's coming towards you. Unfortunately very rare. And in kids usually if the tricastin valves cyanotic rather than a high pressure gradient across it, a lot of that extra flow will just be sitting in their liver. So again the paddle. Meagley is going to be your bigger clue there. Um And then patients with an asd again this will be a huge asd so not super common but those are things to um Let's see. And then thinking of radiation again, thinking of flow of blood. Um So most commonly we have some here. So thinking of systolic murmurs which is again going to be most common. Um If you have, so we'll go to this one here with PS. So you might hear sort of a flow murmur at the left upper sternal border. And then as you kind of move your stethoscope up left and right away from it, you'll hear a little bit of radiation of that murmur so it's not quite as loud in that area, but that's the flow. That's sort of the direction of the branch pulmonary arteries. And so you have flow across the valve and then the p a S. Similarly, if you have branch pulmonary stenosis, you would hear that radiating to the back again because that's where the pulmonary arteries are directed towards patients with a s. You'll hear that again at the right epistolary border. And then we think of that as radiating upwards to the carrots. That's where that aortic that ascending aorta is directed towards. And so that would be the spot to listen is up in there now. Um thinking of em are again you hear that sort of at the apex but you'll hear it up to the left, accelerate a bit. I usually say okay I'm gonna listen to your I'm gonna listen to your heart under your left armpit, yep. That's weird. But that is the spot I listened to for M. R. And then I'll ignore some of the diastolic members again. This would all be abnormal. Thinking of pitch. This is kind of one of my favorite things to start going through with residents initially is first. Okay. Is it is it sisterly isn't diagnostically, is it? S one coincidence or regurgitation or is it ejection type? Um And then I think of pitch. And so a high pitch murmur or high frequency, it's going to um indicate a high pressure gradient between those two areas and this is actually best friend with a diaphragm. Later stethoscope here, it's that sort of larger part um a lower pitch Marmor is going to indicate a smaller pressure gradient. And this is best heard with the bell. And so the other thing to to tell you guys is within pedes. I realize not everyone has a pediatric stethoscope. I don't have mine on my desk here, but I actually have an adult style one where both sides have the diaphragm on it and if you want to use the bell, but without switching it, you can still have the smaller diaphragm option. You just push a little bit harder and that will actually create the same effect as a bell. Um The other thing some of my colleagues do is they actually take the rubber part off of it so they might have on one side, the normal diaphragm and on the other side the bell, but then they take the rubber off of the bell um saying that that can actually help you hear these sort of low frequency sounds even better. So just kind of tricks for you to use. Um And then next in terms of thinking of murmurs, we think of the quality. And so this is just, you know, is it harsh? Is it musical or vibrate Torrey? Like the stills murmurs? Is it kind of a rumbling murmur we think of like when you have a diastolic flow murmur across the mitral valve that might be a diastolic rumble is sort of the term that we would use for it versus blowing. You know if you think of my Children agitation that will create this sort of blowing sound murmur again, I'm not really going to impersonate these. There are examples that I will give you guys links to to later kind of go through and listen to those examples. Um And then we also think of positional changes, right? If any of you have been to cardiology clinic were often having patients you know, lie down, sit up squat down, stand up el salva, those, those can all help us sort out and differentiate between different types of murmurs. Um And so I'll kind of go through some of these in general. And so what we think of is with inspiration and expiration. And so again, remembering when you take a deep breath in your diaphragm moves down, you get more negative pressure in your thorax, higher systemic venous return. And so that's all going to the right side initially. And so that's why any warmer on the right side. Whether it's a truck husband stenosis in the rare case or most commonly pulmonary stenosis, that will be louder when the patient takes a breath in versus a patient who say has aortic stenosis, they that will actually sound softer when they take a breath in. Sorry, they take a breath in. But when they take a breath out, they actually have more flow coming back from the pulmonary veins to the left side. And so listening and watching that patient breathe in and out for several cardiac cycles can help you distinguish between those two. Um Similarly anything that increases preload um that'll increase all murmurs in general. And so things that we would have them do squat down rapidly that will have all that sort of lower venus blood come back or if they're lying down have them raise their legs that will bring everything back to their heart. The other thing you can do to I think of it more babies um like if they're sort of in the nicu or something is I'll push on their liver and that will also bring back more blood to their heart initially. Um On the other hand, anything that decreases pre load will such as val salva or standing. So val salva, you're increasing your inter thoracic pressure that will decrease murmurs. Um And then increasing after load. Like having them do a hand grip that will increase regurgitate murmurs because you increase after load, your aortic pressure is higher. You will actually have more flow, choosing to go to the left atrium instead and then decreasing after load. I've actually never given ammo nitrate. But that's sort of the textbook classic example given decreasing after load will have the opposite effect. Um Probably one of the bigger ones to think of would be aortic stenosis and hope come this might apply especially if people are doing sort of sports screenings for patients and you hear a murmur and you're like, oh gosh, is this like a flow murmur or is this actually you know something concerning more like a. S. Or hokum these would be the maneuvers to do. And so again A. S. Is a left sided um a left sided lesion. And so you think of that increasing as they breathe out. It will increase if you increase that preload so you get more flow to the left heart, decreasing their pre load will decrease it. Same thing with handgrip. Um And then the other kind of fun one to think about is um help them with rapid squatting or passive leg raising that will actually decrease it. Um And so that might be a way to like oh is this just valve ras or is this truly a thick LV. Outflow tract? Um That's how these maneuvers can sort of distinguish between them. Again, if you're concerned about either of those things, you're obviously going to be sending to the cardiologist. Um It's sort of from an academic standpoint it can be kind of fun to have patients go through these various maneuvers to get a sense of what what might be going on. And then here are just some general outlines to think of when you're seeing a patient and they have some form of murmur, how do you differentiate? Okay, this is probably totally innocent and they're fined or this needs referral? I'm concerned this is more likely something wrong. And so systolic murmurs can be innocent, obviously anything diastolic is pathologic um The shape of it. Again, if it's an injection type that can be just a flow murmur. But if it's anything hollow systolic S1 coincidence that's some form of defect. And now pathologic, this also includes sort of a small muscular VSD. But this is clearly not completely normal cardiac anatomy, Similarly intensity anything great 1-2, it's likely innocent. Three or greater are sort of where we think it's reasonable to refer. I've had plenty of people refer a patient and say, you know what? This sounds completely like a stills moment. It's just a bit louder than typical. I see a lot of those patients and those are great because often the pediatrician has already told the family, hey, this is totally fine. I think it's going to be completely innocent. It's just worth a quick evaluation by the cardiologist to make sure. And so those are really fun because I see those patients I get an E. K. G. I examine them and I say, yeah, I completely agree. You know, you've got a great pediatrician. This is an innocent still's murmur. Um and yes it's a bit louder than typical. And so that can actually be really nice both for our family and the pediatrician to kind of just reassure them before they're coming. Especially if that's sort of the case. Um And the quality we think of sort of softer libra torrey murmurs are often in the innocent category. Whereas the very harsh kind of sound, those are more typically something pathologic. And then when they're lying down and it's louder, that's good. If they're standing in its louder, that's bad. Um Similarly just thinking of other findings on exam. So everything else is normal and all they have is this potentially innocent sounding murmur? That's usually a reassuring thing. Versus if there's a murmur plus murmur plus something else that's definitely more concerning. Um I'll quickly go through because it looks like I'm running out of time. I'll quickly go through some of these innocent murmurs just because these are the most common ones you will see or have likely already seen a lot of. Um so still's murmur is the most common thing. I hear it all the time. And I think it's actually really fun and cute. So typically that 2 to 8 year old age range, you know, sort of late toddlers, early childhood, it can be anywhere sort of in this range sort of eight packs left, lower sternal border, left, mid. I've definitely had some in this right upper sternal border that turned out to be a still's murmur. Um And sort of the various terms it's, it's vibrate, Torrey. It's musical buzzing bouncy is the term that I heard once in medical school and it kind of stuck with me. Um or some have described it as cooing dove, the reason for it, no one's ever described. You know, there's some question of whether it's flow going through those Kordell um tissue and the L. V. That makes this sort of musical plucking sound, who knows? Um And then again is the systolic ejection murmur and then when they sit or stand it should either disappear or sort of more localized to the left, Lower sternal border. Um venus homes are really fun. Um So this is a similar age group, a little bit younger, sort of 2 to 6 years old. It's typically about the right, upper sternal border, occasionally on the left. Um But you think of I think of it kind of like the sbc return and so blowing, roaring, wheezing distance sounding are kind of the descriptions but very soft and quiet. This couldn't be like a harsh blowing murmur. It's just kind of a like think of wind blowing per se. Um And this is continuous and you can actually hear it a bit better and diastolic. Um And what you do is if you're not sure of what this is, you lie the patient down and then you compress either compress the jugular vein and more often just have them turn their head and that will actually compress some of those veins and the murmur will go away and so that's really fun to listen to them in that period and say oh yes the subpoenas time goes away it's perfect. And this also it's a very reassuring sign. So I think within the years of being a cardiologist. I think there's only been maybe one kid with any pathologic cardiac stuff that had a venus hum. So a venus hum being present, it can actually be reassuring that their heart is completely normal and it's very low filling pressures. Um PPS is something I think everyone has probably heard, especially that new one period, so kind of 0 to 6 months ish. You'll hear it sort of in the para sternal area on the record. E. Um you can hear it out of the ex illa and then sometimes in the back as well. And so very classic murmurs. We hear all the time the way I describe their parents as you know it when they were a fetus. Their hearts, their lungs are filled with fluid. Sometimes the baby's pulmonary arteries just take a little longer to open up. Um And so this this member is very classic for it. Um It's very short systolic ejection murmur, very low frequency because again there's not really much of a pressure gradient there. Um And it should sound the same kind of all the time throughout the record E um as well as when you move their positions around can be very reassuring typically resolves by six months, but I've also seen it up to kind of close to a year or so. Um Carrot breweries I haven't heard a whole lot of these um just kind of go through them quicker. They're sort of childhood to mid teenage years, you'll hear them actually right over the carrots. Um And it can actually sound somewhat harsh, but the thing to do would be this maneuver where you have them hyper extend their shoulders which is in this sort of diagram here where they put their arms down to the side and then push them all the way back and that should actually make them go away. Um The other thing you want to do is to differentiate it from aortic stenosis radiating to the neck. That would obviously be something that's bad. And so you'd want to take a really good listen to that right upper sternal area to make sure they don't have a sort of a s kind of member in addition to do it. And then finally flow members. We hear him quite frequently sort of again that sort of childhood teenage years often sort of left mid left upper sternal border usually from the kind of pulmonary valve because that's the one that's just right under the sternum. Again a short systolic ejection murmur and that should actually disappear. Get quieter if they sit or stand up. Those can be very helpful things to do and then pathologic murmurs. I won't go through these in great detail, but these are all things that can be common and would be a reason to refer and have a cardiologist evaluate them again. This yellow is the S. One, this white is the S. Two. And so these sort of phonographs show when the murmurs occur within the cardiac cycle. Um So take home points to be, you know, a consultation is just one component of the pediatric cardiac exam. Um And really considering the physiology of each of these heart sounds can really help differentiate what it might be an innocent versus pathologic. Again, I went through these common murmurs with you just based on phonographs anyway, um and then reasons to refer to us to be if if they're concerning or especially if there's something else by history exam that's also off. Um My clinic attending and fellowship with me would say if it's a murmur plus that's concerning, you know, just a soft, innocent member on its own fine. But if you've got probably a still's murmur but oh by the way, they're also not growing something may be up unless you can explain it in another way. Um I always include in my talks. These are some really excellent, just general cardiology resources. This top row is very much at the sort of pediatrician kind of general cardiac level. And then these lower ones are a bit more advanced. I think this book, David titles um book on neonatal cardiology is excellent. It really walked through a lot of the path of physiology. Um And then Moss and Adams is just wonderful as well. And then finally I put these two links on here. So again we'll send these slides out or post them somewhere. Um These are two resources that are really great in terms of actually listening to heart sounds, um they're recorded from actual patients. They're not 100% perfect. Obviously listening to patients with specific lesions is better, but this can be a nice step if you want to kind of spend some time just listening to various murmurs and it has nice descriptions to with it. Um um So thank you everyone for having me to this talk. I want to thank Tabatha. She and I were coordinating together before this san Diego Lol is one of our administrative people who helps run are sort of outpatient and inpatient cardiology. She's been an excellent resource. Um And then our fellows to for sort of starting off some of these murmurs talks and really providing a lot of good teaching. Um And then finally I have this slide and how to refer your patient to us. I unfortunately don't have a specific cardiology slide for you. Um I think my email maybe posted somewhere as well, you're always more than welcome to reach out to me or any of my colleagues. Um But these are sort of the general ways to help get patients to see us at UCSF And it looks like I've got one question, oh yeah, I can put the websites up again, yep, someone just asked if I could put the websites up again for listening to the murmurs. I will definitely go ahead and do that too. And while she's doing that, I'm just gonna say thank you again and please, if you have questions, go ahead and start filling out the Q. And A. And Doctor Crystal you will get to them. Um Thank you again for doing that. And then, oops, let's see. Yes. And then we will send out the hearse slides to everybody who ending. Um So please make sure you fill out your your um evaluation. So we'll get that to you and then we'll send out her slides including these links so that you guys can access them. We'll put in a pdf so you can probably click on the link and it'll take it straight there. Um And are there any other questions, where do you see patients right now? Um So personally I see patients admission baby. Typically each of my colleagues and I have on the mission Bay side. We each have sort of the day we go there. We also have a ton of actually I should have brought up. I have a slide that I actually show our fellows when they first get here to figure out where all of our patients can be seen. And so we have colleagues up as far north as you. Kaya and Eureka who are seeing patients. We have colleagues all the way out to Modesto Stockton in between like in napa we have several up and down the East Bay Fremont Oakland. Um And then we have actually as far south as nativity in one of my colleagues Emilio is down there. Um And then we also have Lakatos and SAn mateo. So basically anywhere a child exists in the bay Area or even sort of out from there we have someone very nearby. And then I forgot there's marin and santa rosa as well. Yeah that's what I cover. The marin and Sonoma counties. So I know them. I know dr dr Rosenfeld over there. Yes. So any which is great. I think cardiology is so one of those the specialties is so wide which is awesome you know napa and um and Fairfield where you have dr Bose and then you have you go like you said you have doctor Quesada down in and dad and you know you guys go all the way out east into the death toe, we just are so happy to have all of you guys. And dr johnston says excellent presentation. And there was a question about the CMI um forms and you'll get that as soon as well, you log off when we finish the lecture it will pop up and if you don't get it please contact us we will make sure to get that to you. So if there are no more questions we'll see one brief thing. So we're just started thinking in terms of referrals. So I my other hat is actually helping with some of the outpatient clinic space. And so one thing we've done in the last year is sort of add the ability for our access center to schedule patients. And so I actually should have put the referral up here too. I included in my final one. But basically what happens is when we get a referral for any patient, the first thing we look at is where does the patient live? You know, we want them to be seen as local and convenient for the family as possible. And then we look into okay who's in that area and what sort of subspecialties within cardiology do that? They do. And so that's something that we do just as a group to make sure that they get to the right provider, the right location. And if there is some subspecialty related things like say they have an asd and they're being referred by someone for a calf closure. We want them to see a calf doc so that family can really get that information up front or if they have some, you know, heart failure issue. Um that would be something we get them in to see some of our sub specialists. So that's something we also try to do as well. Okay so we have some questions. Oh great. Let's see. So one person asked, what is some of the language that you use to reassure families about an innocent murmur. Many of the families I care for become very anxious when I say that I hear a soft, innocent murmur and want to know why it's there what to do. Absolutely. Um So as a cardiologist is a little easier for me to be able to reassure them. Um But one thing I talked about even before I've examined the child so again if they're referred for a murmur I kind of have a heads up already. But what I'll say is hey you know I'm going to take a listen to your child. It sounds like the pediatrician heard this extra heart sound just so you know there are a ton of normal heart sounds that we can just here. And then I kind of talked through with them a little bit again before I listened and saying it depends on where it is and what it sounds like. Um And then I actually kind of go into a little bit of detail about the still's murmur kind of thing. Um And so it definitely depends on the family for sure. Um I will say the other thing that I'm able to do in a cardiology offices rely on the E. K. G. And so I do EKGs on all of my patients when I first see them. And so I actually bring that into the equation and I'll say hey look they have a normal E. K. G. That doesn't just tell me about that rhythm that tells me about their chamber sizes are normal. Their heart chambers aren't thickened. You know I can I can kind of use that a bit more. Um but I think kind of chatting with them a little bit about the heart sounds before listening to them can be helpful. Um and then giving them just a little more higher level description often, you know, as someone who appears younger, which I'm not sad about, it definitely looks like more of a junior attending. I think that can sometimes be helpful too. And there's also a question about what kind of stethoscope to use. Ah give me one second actually, I can show you what I've got. So personally I have always just used the sort of standard Littmann stethoscope. Um Again I have sort of the larger diaphragm here and the smaller diaphragm here. Some people will keep the diaphragm here and then make this into the bell by taking out that diaphragm plus minus taking off this sort of plastic bit here. Um They're definitely sort of more expensive, maybe higher level um stethoscopes you can use. But personally I've been very comfortable just using the standard and not spending a whole ton of extra money on something else. Um In terms of teaching purposes, there are some that my colleagues have that either have two separate um your pieces to it and so you can put the stethoscope down and two people listen at once um where there are ones that actually record heart sounds um Again, I don't think any of those are really necessary. I I would say anyone should be able to just use the standard Littman um and get a really good exam. Again if it's a quiet room and a calm child which are not always within our control. Mm hmm. Perfect. Okay, so it's time it's 1 30 we're just going to close it out and again I'm going to say doctor thank you to dr Australia and please don't forget to fill out the evaluation forms. It should pop up as soon as we close out. And if you have any questions, please let us know, we will give you dr Talia's um contact information. Well, we'll send her email address along with her slides so you can contact her if you have questions. Thanks everybody. Have a great day. Thanks everyone. Mm hmm.