Perioperative Evaluation of Paediatric Heart Murmurs

Heart murmurs in the paediatric patient are:

Epidemiology and Risk Factors

Congenital cardiac disease:

  • ↑ mortality in non-cardiac surgery by 2x
    Major risk factors:
    • Cyanosis
    • Younger age
    • Complex defect
    • Comorbidities
    • Heart failure

Clinical Manifestations

History:

  • Toxins
    Pre- and peri-natal exposure to:
    • Alcohol
    • Lithium
  • Infections
  • Maternal diabetes
  • Prematurity
  • Family history of:
    • Sudden cardiac death
    • Cardiac disease
    • Sudden infant death
    • Congenital cardiac disease

Examination:

  • Palpation of pulses
    • Assess for equality and delay
  • Palpation of thrills
  • Evaluation of features of murmur
  • Features of right heart failure

Key symptoms include:

  • B
    • Recurrent chest infections
    • Cyanosis
    • Tachypnoea
  • C
    • ↓ exercise tolerance/constitutional symptoms
      • Failure to thrive
      • Feeding difficulties
      • Diaphoresis
      • Fatigue
    • Squatting posture during play
      Suggests ToF spells.
    • Syncope
    • Oedema
      Usually peri-ocular.
  • D
    • Developmental delay

Diagnostic Approach and DDx

There are more detailed tables that cover this in textbooks, but this approach is probably more practical than deciding if a murmur is “musical”

Innocent murmurs:

  • Have no signs of cardiac disease
  • Are not harsh
  • Are not purely diastolic
  • Are not purely pansystolic
  • Have no thrill

Investigations

ECG:

  • Evaluate evidence of ventricular hypertrophy

CXR

Management

Factors favouring postponement, ECG, and paediatric cardiology opinion:

  • Patients <1 year
    Severe pathology may be present in absence of symptoms.
  • Symptomatic patients
  • Syndromic patients

Factors favouring proceeding with surgery prior to evaluation:

  • Asymptomatic
  • Age ⩾ 1 year
  • Normal ECG

Timing of Review

Urgency of cardiology review depends on age:

  • Neonates
    Hours.
  • Infants
    Days.
  • Children
    Weeks.

References

  1. Bhatia N, Barber N. Dilemmas in the preoperative assessment of children. Contin Educ Anaesth Crit Care Pain. 2011 Dec 1;11(6):214–8.
  2. Bester K. Anaesthetist’s evaluation of a child with a heart murmur. Southern African Journal of Anaesthesia and Analgesia. 2013 Jan;19(1):14–7.