How to assess and manage
cardiac murmur, cardiac failure,
cyanosis and arrhythmia in
newborns
Alain Fraisse. Consultant Paediatric Cardiology
The Harley Street Clinic & Royal Brompton & Harefield
NHS Foundation Trust
CHILDREN’S HEALTH CONFERENCE
Disclosure
• Consultant and proctor for Medtronic (pulmonary
valve implantation), Abbot (previously St Jude for
Amplatzer devices) and Med-impulse (NuMed
produces)
Murmurs in neonates: incidence and
echocardiography findings
• Murmurs are reported in 0.3 ‐ 77.4% of babies… depends of size of the study, auscultory
conditions and experience of the examiner
• Murmurs are often organic in newborns: 54% of otherwise normal babies with murmurs had
underlying congenital cardiac disease, with 9% of these babies requiring early cardiac surgery
• Echo findings in 50 term babies with murmurs at the newborn check felt to be clinically
innocent : PFO (100%), PDA (26%), pulmonary branch stenosis (14%). No intervention were
identified in their study group of 50, all spontaneously resolved by 6 months.
• Birmingham NICU: In babies with heart murmur, 2% had major CHD, 38% had minor heart
defects
• Study in Jordan on 309 asymptomatic babies: 68 (22%) with CHD including HLHS in 2 and
critical aortic stenosis in 4 babies
• Ainsworth. 1999
Arlettaz. 1998
Singh 2012
Al Ammouri 2016
Innocent murmurs
– Isolated (no symptôme, Nl heart sounds…)
– Intensity < 3/6 (no thrill)
– Short duration, mostly during mid-systole
– Variables with position of the baby, at lower or right upper sternal edge
– More frequent than organic murmurs…
Organic murmur = Heart disease
• More intense and longer, abnormal heart sounds, continuous or
diastolic, associated with symptoms…
• Congenital heart disease (CHD): anomaly with the heart's structure
and function that is present at birth (excluded: bicuspid aortic valve,
PDA in premature babies).– VSD 30%
– ASD, PDA, pulm stenosis 8%
– Tetralogy of Fallot, coarctation, ao stenosis, AV canal 4-6%
– Single ventricles, common arterial trunk 2%
• 0.8-1% of babies.
• 1/3 will have surgery during infancy, 90% will survive till adulthood
• Urgent referral to a paediatric cardiologist for any murmur that looks
organic
Management in an
asymptomatic newborn
with a murmurExtensive clinical examination is
Mandatory, if possible with pulse oxymetry
No evidence to support the « routine use » of 4-limbs BP, CxR and ECG
Echocardiography should be performed to any neonatewith persistent murmur at birth
The rate of CHD is high (up to 50%) in isolated murmursbut the vast majority of the patients do not need anyurgent management
Many « life threatening » CHD are not associated with a murmur Shenvi. 2013 Taksande. 2014
• 8 days, pansystolic murmur
• Normal peripheral pulses, chest clear, well-
perfused…
• Initial suspicion: muscular VSD
Case example 1
Diagnostic/outcome
• Palpation of the
Precordium: PMI on the
right
• Situs inversus-DORV
with pulm stenosis
• O2 sat: 87%
• Had succesful complete
repair at 9 months
• 2 days old, 3/6 pansystolic murmur
• Asymptomatic
• Normal peripheral pulses, Nl 4 limbs BP
Chest clear, well-perfused…
• Initial suspicion: muscular VSD
Case example 2
Diagnostic and outcome
• Common arterial trunk,
• O2Sat 91%
• Developped progressive cardiac failure at 3 weeks
• Surgical repair at 3 months
• Reoperated in 2016 at 16 yo for RVOT conduit
change
Cyanosis• Bluish discoloration of the tissues that results when reduced hemoglobin in the capillary bed
exceeds 3 (arterial blood) to 6 (capillary blood) g/dL
• Difficult clinical diagnosis (even impossible if O2Sat is >80-85%) in case of anemia (low
quantity of reduced Hb), false + si polycythemia, methemoglobinemia…
• Best seen on fingers, nose, ear, nails, tongue…
• Diagnostic:
– pulse oxymetry:
• Not practical before the age of 1–2 h
• Postductal probe placement
• Comparison between pre and post ductal SaO2:
significant if > 10-15 % difference
• Limited sensitivity good specificity
– Hyperoxia test
• Cyanosis due to CHD if PaO2 < 70mmHg, rise by < 30 mmHg or SaO2 unchanged
Reich JD. 2003
Koppel RY. 2003
Cyanotic CHD
• Transposition of the great arteries
• Tetralogy of Fallot
• Single ventricle
• Total anoumalous pulmonary venous
return
Often life threatening, necessitating
emergency neonatal management
• Management : Prostin infusion
• In case of TGA: balloonatrioseptostomy
• Obstructed TAPVC : surgicalemergency
Heart failure in neonates
• Poor growth and feeding
• Tachypnoea (> 60/min, not very specific, better use Silverman or Down
score), tachycardia
• Puffiness of the eyes or feet
• Sweating, irritability
• Nausea
• Lethargy
• Every neonate with circulatory collapse should be strongly suspected to
have ductal dependant CHD. Prostin infusion to be started
– Other pharmacological options: Diuretics (furosemide and
spironolactone, ACE-I (Captopril…), Beta-blockade…
Causes
• Cardiomyopathies – Acute myocarditis
– Metabolic diseases
– Secondary cardiomyopathies (fistula, obstruction…)
• L-R Shunt – Presentation at around 3-4 weeks
• LVOT obstruction : coarctation ++++
• Pericarditis
• Duct dependent CHD ++++
Aortic coarctation– case example9 days-old, circulatory collapse
Severe aortic coarctation
Irreversible brain damage
Declined for surgery: transcatheter treatment
4x20 mm stent implantation (Cook formula)
1 year later : no further intervention, mild recoarctation
Circulatory collapse - case example
• 5 week old boy, born at 41 weeks via NVD
• BW 3.75kg, no NICU/ SCBU stay
• Seen by GP
– History of poor feeding last 3 days , unsettled, vomited x2
• Examination –
• mottling on chest and arms chest clear
• Temp 36.8, Hr 148
• Referred to AU Registrar
On admission to AU at 12.00
• Alert,
• 12.20 – Temp 37.2
Pulse- 150
Respiration 42
Saturations 99 % in air
B/P 109/59
Weight 4.46kg
• Tolerated a breast feed
Examination at 15.00
• General condition- poor
• Airway- patent
• Breathing- good A/E but grunting
• Circulation- poorly perfused, femoral pulses absent and a systolic murmur present
Palpable liver 3 finger breaths below costal margin
• Disability- agitated, crying
• Exposure- No rashes, afebrile
Diagnosis
• Cardiac – Coarctation
• Metabolic
• Sepsis
Management
• Full Septic screen – Bloods, LP
15.21 VBG
Ph 7.03, Pco2 6.48, PO2 5.13,BE -16.7,HCO3 12.9,lactate 13.8,
Na134, K 6.0, Gluc-5.7
15.30 Ceftriaxone 80mg/kg
15.30 0.9% Fluid bolus at 20ml/kg given
16.10 0.9% Fluid bolus at 10ml/kg repeated
16.10 Temp 37, Pulse-155, RR 53, CRT-3-4 secs
Management
• 16.10 Consultant R/V- Urgent ECHO, Prostin, Intubation
• 16.25 CATS team informed – advised anaesthetic,
Prostin, CXR, Adrenaline , 4 limb B/P.
• 16.25 still poorly perfused , B/P unobtainable. Repeat
BG unobtainable
• 17.00 HR 147, RR48
• 17.20 10% Dextrose 25ml given
Management
• 17.20 Prostin infusion commenced
• 17.45 ECHO performed-
global cardiac dysfunction- all cardiac chambers enlarged
• 17.45 HR 150 B/P 147/78
• 17.50 Adrenaline infusion commenced at 0.2mcg/kg/min
Management
• 18.30 CATS team arrived and care handed over
Cardiac failure in an 858 g premature
baby with large PDA
Lat angiogram
Successful closure with a 4/4 mm
Amplatzer ADO IIAS
Arrythmia
• Benigns:
– Isolated supraventricular
extrabeats : F/U in 1-3 months
– Ventricular extrabeats : R/O
metabolic pb
– Sinus arrhythmia, bradycardia
• Bradycardia:
– AV block, congenital or
acquired
• Tachycardia:
– Supraventricular most often
– Can be poorly tolerated
Age Heart rate 2nd to 98th percentile in
bpm (mean)
0-1 days : 93-154 (123)
1-3 days : 91-159 (123)
3-7 days: 90-166 (129)
7-30 days: 107-182 (140)
1-3 months: 121-179 (150)
Case example: sinus tachycardia1 mo, HR 170-180, Nl clinical examination, Nl echocardiography
Main causes of neonatal bradycardia
1) Sinus bradycardia:
· Hypoxia
· Acidosis
· Infection / sepsis
· Electrolyte abnormalities
· Neonatal hypothyroidism
· Increased intracranial pressure
· Hypervagal states- e.g. high position of NG tube, Gastro oesophageal reflux disease
· Obstructive jaundice
2) Sinus node dysfunction - consequence of direct injury to sinus node
· Central line tip in right atrium
· Congenital heart disease (atrial isomerism, ASD, AVSD, single ventricle, CCTGA)
· Post cardiac intervention (e.g. cardiac catheterisation, surgery)
3) Conduction abnormalities or channel-opathy· Kearne-Sayre Syndrome
· Long QT syndrome
4) Heart block· Congenital- maternal connective tissue disorders
· Acquired- post-surgery, myocarditis, rheumatic heart disease, congenital syphilis,
diphtheria, Lyme disease.
Management of bradycardia
• The approach to treatment and long-term prognosis for bradycardia in
the neonate is highly dependent on the underlying etiology and on the
presence of concurrent factors such as structural heart disease
• ECG with calculation of PR and QTc interval
• Persistent neonatal bradycardia in an awake baby of less than 90 beats
per minute (2nd percentile) in the newborn period should prompt
assessment and investigation
• Emergency treatment: – Resuscitation….
– Atropine 0.02 mg/kg IV/IO; may repeat once; minimum dose, 0.1 mg; maximum dose, 0.5 mg
– Epinephrine 0.01 mg/kg IV/IO q3-5min; use 1:10000 concentration (0.1 mL/kg)
Tachycardia: Case example - 4 days old
ECG 1: recorded at 25mm/sec
ECG 2: recorded at
50mm/sec
Adenosine
Given intravenously (100 to 250 mcg/Kg), has a rapid effect primarily on the AV node, meaning it has most
effect on terminating SVT
Short-lived, but common and unpleasant side effects: flushing, chest and jaw pain and dyspnoea.
Cardiovascular side effects: potential to increase the ventricular rate (in atrial fibrillation in WPW or atrial
flutter with bystander accessory pathway…). Caution should also be taken in children with known sinus
node disease due to potential risk of prolonged asystole.
Treatment
• Vagal manoeuver in
neonate : ice to face
Amiodarone
Class III antiarrhythmic
Advantages: minimal negative inotropic effect, effective on broad range of arrhythmias
Side effects: hypotension, QTc prolongation (but rarely Torsades de Pointes) and fast ventricular conduction of atrial tachyarrhythmia via accessory pathway (blocking of AV node).
Longer term systemic side effects: hypothyroidism, liver dysfunction, corneal microdeposits, photosensitivity and grey facial pigmentation
Dosing:- IV : 15-25mcg/kg/min over 4 hours (NB: 25mcg/kg/min = 6mg/kg total over 4 hours)
of loading dose followed by 5mg/kg/day maintenance (=3.5mcg/kg/min maintenance)
- Oral : 500 mg/Kg OD
Atrial flutter
• Re‐entry mechanism with a
critical zone of conduction
between the inferior vena cava
and the tricuspid valve
• Often well tolerated
• Can lead to circulatory
compromised if 1/1
• Same medications than SVT
Ectopic atrial tachycardia (Automatic mechanism)
)
New onset of
tachycardia
No response to
adenosin
AV dissociation
Ventricular tachycardia
Conclusion
• Extensive clinical examination of the newborn is
mandatory, ideally combined with pulse oxymetry
• Such clinical assessment is important at birth, 8
days check and also at one month
• Referral to a paediatric cardiologist or directly to
a paediatric heart centre might be urgent
