Heart Murmurs: Abnormal Murmur in Children
Guest: Dr. Anthony Hlavacek – Pediatric Cardiology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. Today I’m interviewing Dr. Tony Hlavacek who is a pediatric cardiologist here at MUSC’s Children’s Hospital. Dr. Hlavacek, one of the most common things that might bring a parent with their child to your office is a heart murmur. Just what is a heart murmur?
Dr. Tony Hlavacek: It’s very common for children to have heart murmurs. In fact, about 85 percent of babies have a heart murmur at some time during infancy. A heart murmur is just a noise that we hear when we listen to the heart. Some of these noises can be normal. Some of them can be abnormal. It’s just a sound of blood moving through the heart, sort of like water moving through a pipe. We can sometimes hear blood moving through the heart. It doesn’t mean that it’s abnormal. It just means we can hear it. And there are various things that we can do to figure out whether that sound is abnormal or normal.
Dr. Linda Austin: Now, I would imagine most of the time this is handled by the child’s pediatrician and you actually don’t see that child. Is that right?
Dr. Tony Hlavacek: Yes, correct. Most children with murmurs will be examined by their pediatrician. Pediatricians are well trained on how to determine which murmurs are normal as well as abnormal. So, most normal murmurs never need to see a cardiologist. It’s only the ones that could be abnormal that are sent to us.
Dr. Linda Austin: And so of the ones who are referred to you, and I would imagine all the patients you see are by referral, what fraction of those turn out to be significant, that is, require some kind of intervention?
Dr. Tony Hlavacek: Well, I would say about a third of them have some sort of structural heart disease, meaning, they’re abnormal heart murmurs. And, of those, probably only about a third to a half have anything that we would ever need to do anything about. And, when I see do anything, it could be anything from just giving some medicine to kind of help the heart out, all the way up to some sort of intervention, including surgery.
Dr. Linda Austin: So that comes out to about 90 percent of the time then, even the ones you see as a pediatric cardiologist, that turn out to be cases for watchful waiting.
Dr. Tony Hlavacek: Correct.
Dr. Linda Austin: So let’s talk about that ten percent of the time when it is of more concern and we’ll start with those that end up needing medication. What are the types of murmurs that can be effectively treated with medication? How does that work?
Dr. Tony Hlavacek: The most common type of murmur is some sort of hole in the heart, usually a ventricular septal defect. Sometimes it can be a hole somewhere else but we’ll start with those. We can usually give some medicine that helps get fluid off of the lungs, a water pill per se, and that allows the patient to tolerate the hole better.
Dr. Linda Austin: So it’s a diuretic?
Dr. Tony Hlavacek: Yes.
Dr. Linda Austin: You used the term ventricular septal defect.
Dr. Tony Hlavacek: Correct.
Dr. Linda Austin: Okay, so, let’s talk a little bit about the anatomy of the heart and what a ventricular septal defect is.
Dr. Tony Hlavacek: Sure. So, your heart has four chamber, two top chambers, called atria, and two bottom chambers, called ventricles. The most common heart defect is a hole between the two bottom chambers which allows some extra blood to go back around the heart again, and it makes a noise, called a murmur. So, those little holes are quite common. Usually they close on their own. Every once in awhile we have to give medications and rarely we have to close them.
Dr. Linda Austin: Also called VSD?
Dr. Tony Hlavacek: Yes, a VSD.
Dr. Linda Austin: When a child does get medication, how many years, on average, roughly, I’m sure it varies all over the place, but…
Dr. Tony Hlavacek: Well, usually when we’re using medicine for a heart defect, it’s just to get them through infancy. Oftentimes, as the child grows, they’ll either grow large and the defect will become less significant, or sometimes the defect will close on its own. So, usually, if we’re using medicine for a heart defect such as this, they’re usually only on it while they’re an infant and we’ll usually take them off it before childhood.
Dr. Linda Austin: So it buys you some time?
Dr. Tony Hlavacek: Yes.
Dr. Linda Austin: Now, some of the cases, I would imagine, do go to surgery, is that right?
Dr. Tony Hlavacek: Yes, some of them do.
Dr. Linda Austin: And is that when they’re more severe, or when they don’t close on their own? How do you determine that?
Dr. Tony Hlavacek: The main thing we’re going to look for is whether the child can gain weight, eat well and breathe comfortably. If the child seems to be thriving, growing, eating, gaining weight just great, we’ll leave the defect alone. If they’re having trouble then we’ll think about doing surgery.
Dr. Linda Austin: Let’s walk through the process that you go through to evaluate those murmurs. What are the steps of the evaluation?
Dr. Tony Hlavacek: Sure. The first thing I do, I’ll just examine the patient. I’ll ask the parents about how the child’s eating, gaining weight and just look at the patient to see how comfortable they look. Then I’ll listen to the murmur. Sometimes, just by listening, I can tell that the murmur is innocent and needs no further evaluation. If I think that the murmur needs more evaluation, I’ll usually order an echocardiogram. That’s an ultrasound of the heart. With that test, we can look at the structure of the heart in great detail and see if there’s any abnormality that would be causing that murmur. If we see something that is abnormal, that we need to pay attention to, then we’ll talk to the family and see what kind of intervention is necessary.
Dr. Linda Austin: Now, I’m sure that some parents listening to this are doing so because they have a child that may be about to undergo an echocardiogram. What, exactly, does that procedure entail from the point of view of the patient?
Dr. Tony Hlavacek: It’s just an ultrasound. It’s not painful. It takes about 20 minutes. A sonographer will be with you in a small room. Usually a child can watch TV or listen to cartoons while it’s going on. It takes about 20 minutes and they’ll just put the ultrasound probe on the chest and take pictures of the heart. It’s not a painful procedure.
Dr. Linda Austin: So this is not a particularly scary thing?
Dr. Tony Hlavacek: No, generally not. You know, some toddlers are scared of it just because they’re scared of being touched by people, but it’s not a scary thing. And you’ll get the results back that same day.
Dr. Linda Austin: Now, do you sometimes need to go ahead and do different kinds of imaging, beyond the echo?
Dr. Tony Hlavacek: Yeah. Ultrasound has its limitations. Sometimes there are some structures that are difficult to see by the ultrasound. In those patients, we may need to do something like a CT angiogram. That’s a CT scan where we put dye in the blood vessels and we can take pictures of the heart. We can also do, sometimes, a magnetic resonance imaging, an MRI, of the heart. That’s done fairly frequently. Those are the most common other noninvasive tests that we would do to look at the heart.
Dr. Linda Austin: And those, also, are fairly benign for the child, are they not?
Dr. Tony Hlavacek: Yes. Neither one of those are painful. The most painful part is getting an IV for the CT angiogram.
Dr. Linda Austin: That could be a little scary for a child.
Dr. Tony Hlavacek: Yes.
Dr. Linda Austin: But I am sure that there are ways that you make that less difficult.
Dr. Tony Hlavacek: Yes. We’ll numb their skin and distract them.
Dr. Linda Austin: It must be a very rewarding specialty. I’m sure you have good outcomes.
Dr. Tony Hlavacek: Yes. And the great thing about working with kids is that kids are incredibly resilient. They heal faster than adults. They’re lots of fun. And most kids do really well. I’d say the vast majority of my patients, even if they have somewhat serious heart disease, much more serious than just a hole in the heart, do really well. I have lots of pictures on my wall of kids that are happy.
Dr. Linda Austin: Thank you so much for talking with us today.
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