Guest: Dr. J. Philip Saul - Pediatric Cardiology
Host: Dr. Linda Austin – Psychiatrist
Announcer: Welcome to an MUSC Health Podcast.
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Philip Saul, who is the Chief of Pediatric Cardiology at the Medical University of South Carolina. Dr. Saul, let’s talk about a term that people hear a lot, but may not quite understand which is heart murmurs, what is a heart murmur?
Dr. J. Philip Saul: Sure, Linda. Well, a heart murmur really is just a sound that the heart makes and sometimes that sounds means that something is wrong with the heart and sometimes it’s just a sound that we called an innocent murmur, which means that there is nothing really wrong with the heart, but we can hear a sound through the chest wall and in a child, we can often very clearly hear that because the heart is much closer to the chest wall.
Dr. Linda Austin: So, what’s the earliest age then that a pediatrician might pick up a murmur?
Dr. J. Philip Saul: You can actually hear murmurs sometimes in newborn infants, and almost all of those mean that something is wrong with the heart that may not be something very serious, but it is something that needs to investigated, so if a baby is born and immediately has a heart murmur, they need to get an evaluation by a pediatric cardiologist.
Dr. Linda Austin: I take it then that oftentimes you have situations where there is no murmur and then at a certain age 5-10, whatever a murmur appears?
Dr. J. Philip Saul: Yeah, there are few times in life when we tend to have the appearance of a new murmur; one is a few days after birth, so there are certain problems with the heart that present themselves at two or three days of age when certain changes take place in the body after coming out of the womb. Then around two months of age is another period when we will see some children present with a murmur and again that often represents something wrong with the heart. From about two to three months of age until three or four years of age, usually there aren’t any murmurs and we don’t get too many new presentations of murmurs, but then as children age, they begin to get a little thinner and we will hear some of those innocent murmurs that I was talking about earlier where we can hear the heart, but there is nothing wrong with it. In addition, there are some problems that will just present themselves a little later in life for various reasons.
Dr. Linda Austin: Now, you mentioned that after you hear a murmur particularly in a newborn, but I would imagine later as well, that leads to an evaluation a diagnostic workup, how do you as a doctor begin that workup, what’s the first thing you do?
Dr. J. Philip Saul: We almost always start with the basics which is a physical exam. So, we want to talk to the patient or the family, find out what’s going on and then do a physical exam. For a murmur, the most important part of course is listening to the heart with a stethoscope. A lot of times, we can decide right then in there that this is something that we have to worry about or it’s one of theses innocent murmurs where we don’t really have to worry about it. If we aren’t sure or in many cases even when we have a pretty good idea, then we order an echocardiogram to be absolutely sure and the echocardiogram is an ultrasound of the heart where we can see all the valves and all the working parts.
Dr. Linda Austin: So, just to backup a little bit and to think about what is actually physically causing that murmur, how do you explain it to parents who may not understand the anatomy of the heart very well?
Dr. J. Philip Saul: Sure. Well, the innocent ones are the easiest for me to explain because what I do is I usually go over to the faucet and I turn the one and it makes a noise and yet, I can tell parents there is nothing wrong with this faucet, it just makes a noise and that’s the way the heart is. It is blood flowing through a series of pumps and valves and a lot of times that blood makes a noise as it flows through and you can hear it. The pathologic murmurs, the ones where there is something wrong with the heart, are usually either a hole between the two sides of the heart in the upper or lower chamber or it’s one of the valves has an abnormality; it’s either too narrow or it leaks blood backwards and is not supposed to do that, or a variety of other problems, but it’s usually either a hole or a valve problem.
Dr. Linda Austin: So, then the child has the echocardiogram and is that usually sufficient for you to determine whether you are going to need to do some kind of procedure or there are more studies then after that?
Dr. J. Philip Saul: Yeah, we are pretty fortunate in children that an echocardiogram is a very accurate test and the ultrasound waves; you can see almost everything in the heart of the child. It’s pretty close to the chest wall, the way the lung surrounds the heart is just right where can see things pretty well, so we can almost always come to a definitive diagnosis by echo on what’s there. Now sometime, we do need further testing, but most of the time, the echo answers the question.
Dr. Linda Austin: What are some of the most common anatomical structural problems of the heart that leads to the kind of murmur that you really do need to do something about?
Dr. J. Philip Saul: Well, it turns out that about 1% of all live-born infants have a congenital heart abnormality. About half of those are relatively minor and about half will need surgery at some point. The very most common congenital abnormality is a hole between the two lower chambers of the heart, those are called the ventricles and the hole is called a ventricular septal defect with the septum being the wall between the two sides of the heart and that can present at just a couple of days of age, it can present at a couple of month of age, or sometimes they are really not heard till a little later in life.
Dr. Linda Austin: If they are not heard till later in life, has it been there all long, just not picked up?
Dr. J. Philip Saul: That’s sometimes the case, but there are certain times when you can hear things better because of the way the physiology changes. Now, the nice thing about these is that if they are big enough that they are concerned, they will almost always be heard in the first few months of life.
Dr. Linda Austin: What are some of the symptoms that a parent might observe in their child, who has a VSD -- a ventricular septal defect?
Dr. J. Philip Saul: The primary symptom would be a murmur, would be a sound. When the child goes for the normal pediatric visit at either two weeks or two months of age, if it’s not picked up that way, then what we might see is failure to grow normally, so we call that failure to thrive, we might see a child who breaths a little harder than normal, who sweats a little too much, whose color is a little pale, and who just seems to be working a little too hard physiologically for their stage of life.
Dr. Linda Austin: How do you treat a VSD?
Dr. J. Philip Saul: Again, we are a little fortunate. Their half of the VSDs will actually close on their own in the first year of life. The heart basically hasn’t finished developing in the womb and finishes it up over the first year. So, you know, even the big ones can do that and of course, parents feel very lucky when that’s the case. The rest of them either they are going to be small enough that we don’t need to anything or they can be closed surgically or in the catheterization laboratory.
Dr. Linda Austin: Tell me about that procedure.
Dr. J. Philip Saul: The traditional way to do that is surgically and that’s an open heart procedure. The chest has to be opened, the heart has be opened, and the patient is put on cardiopulmonary bypass and then the surgeon actually fixes the hole either by sewing it closed or putting a patch in; that was actually the very first open heart operation was to repair a ventricular septal defect in a 2-year-old child in 1954 that was done by Dr. Walton Lillehei. Now in recent years, we have developed some devices where the device can be deployed from a catheter in the catheterization lab where they can put just through an artery or vein in the groin, passed into the heart and passed into the hole and then secured in the hole with some special techniques. Most VSDs can’t be closed that way now, but our guess is that in the next few years, we will be able to close a significant portion using that device.
Dr. Linda Austin: What’s the prognosis for kids, who have had a VSD surgically repaired?
Dr. J. Philip Saul: It’s excellent. If the VSD is closed completely, which the vast majority are, then after a very few months, the hole or the patch will completely close over with normal heart tissue and almost all those children will lead a completely normal life with absolutely no problems. Occasionally later in life, there may be some heart rhythm abnormality, which is actually my specialty, but most of those kids do very, very well.
Dr. Linda Austin: Here at the Medical University, how many of those procedures whether it’s through the catheter or an open procedure, how many of those do we do a year?
Dr. J. Philip Saul: We do about 380 surgical cardiac procedures in children a year and about 600 catheterizations. Now, not all of those are for ventricular septal defects, but a reasonable percentage or it’s probably about 20 to 25 a year are either done in the catheterization lab or in surgery just for VSDs.
Dr. Linda Austin: Dr. Philip Saul, thank you so much for talking with us today.
Dr. J. Philip Saul: Thank you, Linda.
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