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Kostopoulou E, Dimitriou G, Karatza A. Cardiac Murmurs in Children: A Challenge For The Primary Care Physician. Curr Pediatr Rev 2019; 15:131-138. [PMID: 30907325 DOI: 10.2174/1573396315666190321105536] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/22/2018] [Accepted: 03/14/2019] [Indexed: 02/08/2023]
Abstract
Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause. Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination. In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.
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Affiliation(s)
- Eirini Kostopoulou
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
| | - Ageliki Karatza
- Department of Paediatrics, University of Patras Medical School, Patras, Greece
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Hundeshagen G, Herndon DN, Clayton RP, Wurzer P, McQuitty A, Jennings K, Branski L, Collins VN, Marques NR, Finnerty CC, Suman OE, Kinsky MP. Long-term effect of critical illness after severe paediatric burn injury on cardiac function in adolescent survivors: an observational study. THE LANCET. CHILD & ADOLESCENT HEALTH 2017; 1:293-301. [PMID: 29581998 PMCID: PMC5865217 DOI: 10.1016/s2352-4642(17)30122-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Sepsis, trauma, and burn injury acutely depress systolic and diastolic cardiac function; data on long-term cardiac sequelae of pediatric critical illness are sparse. This study evaluated long-term systolic and diastolic function, myocardial fibrosis, and exercise tolerance in survivors of severe pediatric burn injury. METHODS Subjects at least 5 years after severe burn (post-burn:PB) and age-matched healthy controls (HC) underwent echocardiography to quantify systolic function (ejection fraction[EF%]), diastolic function (E/e'), and myocardial fibrosis (calibrated integrated backscatter) of the left ventricle. Exercise tolerance was quantified by oxygen consumption (VO2) and heart rate at rest and peak exercise. Demographic information, clinical data, and biomarker expression were used to predict long-term cardiac dysfunction and fibrosis. FINDINGS Sixty-five subjects (PB:40;HC:25) were evaluated. At study date, PB subjects were 19±5 years, were at 12±4 years postburn, and had burns over 59±19% of total body surface area, sustained at 8±5 years of age. The PB group had lower EF% (PB:52±9%;HC:61±6%; p=0.004), E/e' (PB:9.8±2.9;HC: 5.4±0.9;p<0.0001), VO2peak (PB:37.9±12;HC: 46±8.32 ml/min/kg; p=0.029), and peak heart rate (PB:161±26;HC:182±13bpm;p=0.007). The PB group had moderate (28%) or severe (15%) systolic dysfunction, moderate (50%) or severe diastolic dysfunction (21%), and myocardial fibrosis (18%). Biomarkers and clinical parameters predicted myocardial fibrosis, systolic dysfunction, and diastolic dysfunction. INTERPRETATION Severe pediatric burn injury may have lasting impact on cardiac function into young adulthood and is associated with myocardial fibrosis and reduced exercise tolerance. Given the strong predictive value of systolic and diastolic dysfunction, these patients might be at increased risk for early heart failure, associated morbidity, and mortality. FUNDING Conflicts of Interest and Sources of Funding: The authors do not have any conflicts of interest to declare. This work was supported by NIH (P50 GM060338, R01 GM056687, R01 HD049471, R01 GM112936, R01-GM56687 and T32 GM008256), NIDILRR (H133A120091, 90DP00430100), Shriners Hospitals for Children (84080, 79141, 79135, 71009, 80100, 71008, 87300 and 71000), FAER (MRTG CON14876), and the Department of Defense (W81XWH-14-2-0162 and W81XWH1420162). It was also made possible with the support of UTMB's Institute for Translational Sciences, supported in part by a Clinical and Translational Science Award (UL1TR000071) from the National Center for Advancing Translational Sciences (NIH).
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch, 301
University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma
Center, BG Trauma Center Ludwigshafen; University of Heidelberg,
Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301
University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
| | - Robert P Clayton
- Department of Surgery, University of Texas Medical Branch, 301
University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
| | - Paul Wurzer
- Division of Plastic, Aesthetic and Reconstructive Surgery,
Department of Surgery, Medical University of Graz, Austria
| | - Alexis McQuitty
- Department of Anesthesiology, University of Texas Medical Branch,
301 University Blvd, Galveston, TX 77555
| | - Kristofer Jennings
- Office of Biostatistics, Department of Preventive Medicine and
Community Health, University of Texas Medical Branch, 301 University Blvd,
Galveston, TX 77555
| | - Ludwik Branski
- Department of Surgery, University of Texas Medical Branch, 301
University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
- Division of Plastic, Aesthetic and Reconstructive Surgery,
Department of Surgery, Medical University of Graz, Austria
| | - Vanessa N Collins
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
| | - Nicole Ribeiro Marques
- Department of Anesthesiology, University of Texas Medical Branch,
301 University Blvd, Galveston, TX 77555
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, 301
University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, 301
University Blvd, Galveston, TX 77555
- Shriners Hospitals for Children, Galveston, 815 Market St,
Galveston, TX 77555
| | - Michael P Kinsky
- Division of Plastic, Aesthetic and Reconstructive Surgery,
Department of Surgery, Medical University of Graz, Austria
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Elhoff JJ, Shekerdemian LS. The slow burn: are we neglecting potential long-term cardiovascular sequelae of critical illness in children? THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:254-256. [PMID: 30169178 DOI: 10.1016/s2352-4642(17)30123-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Justin J Elhoff
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas 77030, USA
| | - Lara S Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas 77030, USA.
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Williams FZ, Sachdeva R, Travers CD, Walson KH, Hebbar KB. Characterization of Myocardial Dysfunction in Fluid- and Catecholamine-Refractory Pediatric Septic Shock and Its Clinical Significance. J Intensive Care Med 2016; 34:17-25. [PMID: 28030994 DOI: 10.1177/0885066616685247] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE: Myocardial dysfunction is a known complication in patients with pediatric septic shock (PSS); however, its clinical significance remains unclear. The purpose of this study was to characterize left ventricular (LV) and right ventricular (RV) dysfunction and their prevalence in patients with PSS using echocardiography (echo) and to investigate their associations with the severity of illness and clinical outcomes. METHODS: Retrospective chart review between 2010 and 2015 from 2 tertiary care pediatric intensive care units. Study included 78 patients (mean age 9.3 ± 7 years) from birth up to 21 years who fulfilled criteria for fluid- and catecholamine-refractory septic shock. Echocardiographic parameters of systolic, diastolic, and global function were measured offline. They were correlated with admission Pediatric Risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction scores, vasoactive-inotrope score (VIS), β-type natriuretic peptide (BNP), lactate, type of shock, duration of mechanical ventilation (MV), intensive care unit and hospital length of stay, and mortality. RESULTS: Overall, 28-day mortality was 26%, and 88% patients required MV. Prevalence of LV dysfunction was 72% and RV dysfunction was 63%. LV systolic dysfunction (fractional shortening z score <-2) was significantly associated with PRISM III, VIS, and BNP. RV systolic dysfunction (tricuspid annular plane systolic excursion z score <-2) was significantly associated with cold shock. LV and RV diastolic dysfunction did not have any significant clinical associations. No echocardiographic measures were associated with mortality. CONCLUSION: Myocardial dysfunction is highly prevalent in PSS but is not associated with mortality. LV systolic dysfunction is associated with a higher severity of illness, use of vasoactives, and BNP, whereas RV systolic dysfunction is associated with cold shock. Further studies are needed to determine the utility of echo in the bedside management of patients with PSS.
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Affiliation(s)
- Feifei Z Williams
- 1 Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ritu Sachdeva
- 2 Division of Pediatric Cardiology, Emory University of School of Medicine, Atlanta, GA, USA.,3 Children's Healthcare of Atlanta, Atlanta, GA, USA.,4 Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Curtis D Travers
- 5 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Kiran B Hebbar
- 1 Division of Pediatric Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA.,3 Children's Healthcare of Atlanta, Atlanta, GA, USA
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Borde L, Amory H, Grulke S, Leroux AA, Houben RM, Detilleux J, Sandersen CC. Prognostic value of echocardiographic and Doppler parameters in horses admitted for colic complicated by systemic inflammatory response syndrome. J Vet Emerg Crit Care (San Antonio) 2014; 24:302-10. [PMID: 24690095 DOI: 10.1111/vec.12177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 02/04/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the prognostic value of echocardiographic parameters of left ventricular (LV) function in horses with systemic inflammatory response syndrome (SIRS). DESIGN Prospective observational study. SETTING Veterinary teaching hospital. ANIMALS Forty-one horses admitted for colic with clinical evidence of SIRS. INTERVENTIONS All horses underwent Doppler echocardiographic examination on admission. LV echocardiographic parameters, including pulsed-wave tissue Doppler imaging parameters, were compared between nonsurvivors (n = 29) and horses that survived to discharge (n = 12). MEASUREMENTS AND MAIN RESULTS With comparable heart rate and LV preload estimate, LV stroke volume index, the velocity time integral, deceleration time, ejection time of Doppler aortic flow, and peak early diastolic myocardial velocity were lower in the nonsurviving than in the surviving horses, while pre-ejection period to ejection time ratio (PEP/ET) of Doppler aortic flow and the peak early diastolic filling velocity to peak early diastolic myocardial velocity ratio (E/Em) were higher (P < 0.05). A cut-off value of 0.26 for PEP/ET predicted mortality with 100% sensitivity and 42% specificity (area under the receiver operating characteristic curve: 0.71), whereas a cut-off value of 2.67 for E/Em predicted mortality with 100% sensitivity and 83% specificity (area under the receiver operating characteristic curve: 0.89). CONCLUSIONS Echocardiography may provide prognostic information in colic horses with clinical evidence of SIRS. Especially, PEP/ET and E/Em could be useful markers of systolic and diastolic dysfunction, respectively, to detect horses with a high risk of death requiring more intensive cardiovascular monitoring as it has been reported in human patients with septic shock.
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Affiliation(s)
- Laura Borde
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Boulevard de Colonster 20, B41, 4000, Liège, Belgium
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Abstract
Cardiovascular dysfunction is common in severe sepsis or septic shock. Although functional alterations are often described, the elevated serum levels of cardiac proteins and autopsy findings of myocardial immune cell infiltration, edema, and damaged mitochondria suggest that structural changes to the heart during severe sepsis and septic shock may occur and may contribute to cardiac dysfunction. We explored the available literature on structural (versus functional) cardiac alterations during experimental and human endotoxemia and/or sepsis. Limited data suggest that the structural changes could be prevented, and myocardial function improved by (pre-)treatment with platelet-activating factor, cyclosporin A, glutamine, caffeine, simvastatin, or caspase inhibitors.
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