Pediatrics - Congenital Abnormalities Module
This pediatric-congenital murmurs module includes six lessons. Each lesson includes a textual description, audio recording, dynamic waveform video, and a cardiac animation. Optionally, a quiz can be taken to measure comprehension and listening skills. Users who have selected our Auscultation-Basics, Essentials or Advanced plans can print achievement certificates and view their progress and scores using our personalized dashboard.
Auscultation of pediatric patients is usually conducted early in the physical exam. Keeping the infant or child quiet and cooperative is an essential skill. Auscultation of infants can be performed while a parent holds the infant. In addition to the normal anterior auscultation areas, auscultating posterior locations may be helpful.
Because congenital abnormalities can cause malformations, listen to all locations with both bell and diaphragm. Take note of these murmur attributes:
- Timing: early, mid, late or pansystolic
- Loudness and its pattern during systole
- Quality (harsh, blowing or musical)
- Murmur changes during the respiratory cycle
The lessons in this course present several types of congenital murmurs, their attributes, and clinical correlations.
Start Pediatric - Congenital Course
Pediatrics - Congenital Abnormalities Lessons
Coarctation of the Aorta
This lesson presents coarctation of the aorta, a congenital abnormality. S1 is normal, and the S2 sound is intensified. A diamond-shaped murmur spans most of systole while a high-pitched decrescendo murmur occurs in the first half of diastole.
In the cardiac anatomy video, observe a constriction in the descending aorta, which is responsible for the systolic murmur. There is regurgitant blood flowing from the aorta into the left ventricle producing the diastolic murmur. The left ventricle wall thickness is increased due to aortic pressure elevation caused by the aortic coarctation.
Patent Ductus Arteriosus
In this lesson, we discuss patent ductus arteriosus. Before birth, the two major arteries—the aorta and the pulmonary artery are connected by a blood vessel called the ductus arteriosus. Shortly after birth the patent ductus closes and turns into a ligament. However, in abnormal circumstances, the patent ductus remains open, allowing blood to flow from the aorta into the pulmonary artery causing a strain on the right ventricle.
The first heart sound is normal. The second heart sound is obscured by a continuous crescendo-decrescendo murmur which runs from the beginning of systole to the end of diastole peaking at the second heart sound.
This murmur can be auscultated at the pulmonic position.
In the cardiac anatomy video, observe an enlarged left atrium and left ventricle. Turbulent blood flow from the aorta to the pulmonary artery through the patent ductus.
Atrial Septal Defect
Atrial Septal Defect is a congenital condition associated with abnormal blood flow between the left atrium and the right atrium. Before birth there is a large connection between right and left atria. During fetal development, the connection gradually disappears. However, in some cases, this opening persists and is known as an atrial septal defect.
Both the first and second heart sounds are split. The second heart sound splitting is fixed at 80 milliseconds. There is a brief diamond-shaped murmur in early systole and another brief diamond-shaped murmur in early diastole
This murmur was auscultated at the pulmonic position.
In the cardiac animation video, observe an enlarged right atrium and right ventricle. You see turbulent blood flow across the tricuspid valve between the right atrium and the right ventricle (the diastolic murmur). This is caused by blood flow from the left atrium into the right atrium through the atrial septal defect. There is additional turbulent flow into the pulmonary artery causing the systolic murmur.
Ventricular Septal Defect
Ventricular Septal Defect is a congenital condition associated with abnormal blood flow between the left ventricle and the right ventricle. During fetal development, a wall develops creating right and left ventricles. In abnormal cases, a defect in the wall persists, allowing blood flow from the left ventricle into the right ventricle. This condition is known as a ventricular septal defect.
The first heart sound is normal, and S2 is unsplit. A third heart sound followed by a short diamond shaped diastolic murmur is present. A medium-pitched murmur fills all of systole.
In the anatomy animation, observe an enlarged right ventricle and an enlarged left atrium. You see turbulent blood flow from the left ventricle into the right ventricle through the up portion of the septum (the systolic murmur). There is further turbulent flow into the left ventricle from the left atrium causing the diastolic murmur. This is caused by VSD induced increased blood flow across the mitral valve.
This ventricular septal defect was auscultated at the tricuspid position.
Tetralogy of Fallot
This lesson presents Tetralogy of Fallot, which is a congenital condition often called Blue Baby Syndrome. It is characterized by four abnormalities:
- pulmonic stenosis
- increased thickening of the right ventricle
- a ventricular septal defect
- overriding aorta
S1 and S2 are normal and unsplit. There is an aortic ejection click in systole. A diamond shaped murmur following the click and ending well before the second heart sound.
In the cardiac animation video, observe the turbulent flow from the right ventricle into the pulmonary artery across the stenotic pulmonic valve and turbulent flow from the left ventricle to the right ventricle (the ventricular septal defect). The right ventricular wall is thickened.
At the tricuspid position, you will hear the ventricular septal defect. At the pulmonic area you will hear the pulmonic stenosis. Both create diamond-shaped systolic murmurs.
This is an example of Ebstein's Anomaly, a congenital abnormality. The first heart sound is increased due to thickening of the tricuspid valve leaflets. The second heart sound is normal. A rectangular murmur of tricuspid regurgitation fills all of systole. An opening snap occurs 100 milliseconds into diastole followed by a decrescendo-crescendo murmur of mitral stenosis. These findings are all a manifestation of downward displacement of the tricuspid valve into the right ventricle
In the anatomy video you can see the enlarged right atrium and the small right ventricle. The upward plume from the right ventricle to the right atrium represents the systolic murmur. The downward plume from the right atrium to the right ventricle represents the diastolic murmur.
This murmur can be auscultated at the tricuspid area.
After completing all lessons in a coarse, a quiz becomes available. If the user successfully completes a quiz, results are saved to the user's dashboard and a certificate can be printed.
Reference GuideFor subscribers, we provide a comprehensive heart sounds and murmurs reference guide. For each abnormality, one or more sound recordings are available along with text, phonocardiogram and cardiac animation.
Authors and ReviewersAuthored by Dr. Barbara Erickson, PhD, RN, CCRN, Dr. Jonathan Keroes, MD and David Lieberman, Developer, Virtual Cardiac Patient. Last Update: 12/12/2021.
Registered users can earn a certificate of achievement for this module by reading all content and then earning a passing score on this module's quiz.
Completed modules and related scores can be viewed on the dashboard.
Heart Sounds and Murmurs Across the Lifespan (with CD)
by Dr Barbara Ann Erickson
ISBN-10: 0323020453; ISBN-13: 978-0323020459
Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition
Elsevier-Health Sciences Division
Barbara A. Erickson, PhD, RN, CCRN
Heart Sounds Made Easy with CD-ROM: (with CD-ROM) 2nd Edition
Anthony P. Salmon
- NCBI Review of Heart Sounds and Murmurs: A Practical Guide
The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds And Murmurs
Jonathan Keroes, David Lieberman
Publisher: Lippincott Williams & Wilkin)
ISBN-10: 0781784425; ISBN-13: 978-0781784429
Ventricular Function Curves in the Exercising Dog
JONATHAN KEROES , ROGER R. ECKER , and ELLIOT RAPAPORT
Circulation Research, Vol. 25, No. 5
Electrocardiographic changes associated with ritodrine-induced maternal tachycardia and hypokalemia
American Journal of Obstetrics Gynecology, VOLUME 154, ISSUE 4, P921-923, APRIL 01, 1986
Susan K Hendricks, MD, Jonathan Keroes, MD, Michael Katz, MD
A Multimedia Guide to Heart Sounds and Murmurs
January 2007 JAMA The Journal of the American Medical Association 297(2):217-218
DOI:10.1001/jama.297.2.217. M. Saleem Seyal, MD, Reviewer