var340=Although effort intolerance may occur in moderate to severe disease.&var3 39=True&var338=Also in Williams and Allagille syndromes.

&var337=True&var336=The narrowings may be ballooned or stented.&var335=True&var334=The chest X-ray can b e very helpful, particularly in unilateral stenosis.&var333=False&var332=An atri al communication is a reasonably common association and may lead to cyanosis.&va r331=False&var330=This may be the case with quite severe disease.&var329=True&va r328=Branch pulmonary artery abnormalities are common in tetralogy of Fallot.&va r327=True&var326=Most probably arising from collateral arteries.&var325=True&var 324=They are most easily heard over the back and in the axillae.&var323=False&va r322=The majority disappear within 6 months as the pulmonary arteries grow.&var3 21=True&var320=Although it is more likely to be a cause in a relatively young pe rson, since it can be excluded simply by feeling the femoral pulse, it should be considered in all cases.&var319=True&var318=In neonates, right ventricular hype rtrophy is more common because of pulmonary hypertension.&var317=False&var316=Th e aorta may dissect at its arch, at the coarctation site, or because of a mycoti c aneurysm.&var315=True&var314=This is due to associated intracranial aneurysms, as well as systemic hypertension.&var313=True&var312=Because of the abnormaliti es in the aortic wall and vascular bed in patients with coarctation, abnormal hy pertension, particularly systolic hypertension often persists despite successful relief of the obstruction.&var311=False&var310=The endocarditis may be at the s ite of the coarctation, or may occur on a coexisting bicuspid aortic valve.&var3 09=False&var308=It is best heard just to the left of the spine at the back.&var3 07=True&var306=The presence of a 3 sign is diagnostic of coarctation.&var305=Tru e&var304=Like many forms of structural heart disease, the patient is often asymp tomatic, even in the presence of significant disease.&var303=False&var302=Estima tes of the ratio vary from 1.3 to 1 to 3 to 1.&var301=True&var300=The presence o f an atrial communication will lessen the left atrial pressure, and so the pulmo nary hypertension, but will lead to a decreased systemic cardiac output.&var299= True&var298=The ECG will usually show signs of left atrial hypertrophy, and may show right ventricular hypertrophy if there is pulmonary hypertension.&var297=Fa lse&var296=Mitral stenosis leads to pulmonary hypertension and so may produce au dible pulmonary regurgitation.&var295=True&var294=An opening snap is more common in rheumatic disease, and less common when the valve is congenitally abnormal.& var293=False&var292=Rheumatic mitral stenosis may lead to calcification and fibr osis of the valve as the condition progresses.&var291=True&var290=Bacterial endo carditis will generally lead to worsening regurgitation.&var289=True&var288=The balance between regurgitation and stenosis may alter over time.&var287=True&var2 86=This depends upon the patient being is sinus rhythm, and atrial fibrillation is a common complication of mitral stenosis.&var285=False&var284=The apical thri ll is diastolic, although it can be easy to mistime it.&var283=False&var282=Alth ough rheumatic fever is now uncommon in developed countries, worldwide it is sti ll the commonest cause of mitral valve stenosis.&var281=True&var280=The click of mitral prolapse is best heard at the apex, as is that of a bicuspid aortic valv e.&var279=True&var278=Because mitral valve prolapse is associated with Marfan sy ndrome it may be present in several members of the same family.&var277=True&var2 76=The incidence of mitral regurgitation rises with age due to 'functional' mitr al regurgitation and degenerative mitral valve disease.&var275=False&var274=The mitral valve may be stenotic, regurgitant, or both following rheumatic fever.&va r273=True&var272=Acute mitral regurgitation following myocardial infarction is d ue to papillary muscle rupture and combined with impaired left ventricular funct ion has a poor prognosis.&var271=False&var270=The atrioventricular valves are ab normal in atrioventricular septal defect and so regurgitation is common.&var269= True&var268=It is best heard at the apex. A systolic murmur best heard at the lo wer left sternal edge is likely to be tricuspid regurgitation or a VSD.&var267=F alse&var266=Mitral valve prolapse is more common in women.&var265=False&var264=T he extra regurgitant fraction may cause a mitral diastolic flow murmur.&var263=T rue&var262= In severe disease, the left atrial pressure may equalize with the le ft ventricular pressure part way through systole and the murmur stops before the end of systole.&var261=False&var260=This is true if right ventricular function is good. In Ebstein s anomaly, pulsatility may be lost due to poor right ventricul

ar function.&var259=True&var258=Particularly in Ebstein s anomaly, when the right atrium and atrialised portion of the right ventricle may be very dilated.&var257 =True&var256=There may be tricuspid and pulmonary regurgitation after surgical r epair of tetralogy.&var255=True&var254=They are a common in association with Ebs tein s anomaly. This may be because the tricuspid regurgitation stretches the righ t atrium and does not allow the PFO to close.&var253=False&var252=There may be m ultiple accessory pathways in Ebstein s anomaly. Supraventricular tachycardia may be the first presentation of Ebstein s anomaly.&var251=True&var250=Tricuspid regur gitation is systolic.&var249=False&var248=This is because the right ventricle is typically a low pressure chamber. This will not be the case if there is pulmona ry hypertension.&var247=True&var246=Although as noted above this may not occur i s some cases of Ebstein s anomaly, or if there is right ventricular failure.&var24 5=True&var244=Although Ebstein s anomaly may be fatal in infancy, the presentation may be very variable and some people are asymptomatic well into adulthood.&var2 43=False&var242=The septal leaflet of the tricuspid valve may become adherent to the site of the VSD leading to regurgitation.&var241=True&var240=It may occur w ith other left heart obstruction, such as coarctation and mitral stenosis, or wi th more complex conditions, such as double outlet right ventricle or complex sin gle ventricle circulation.&var239=True&var238=There may also be mitral regurgita tion.&var237=True&var236=Typically the pulse is small volume with isolated obstr uction.&var235=False&var234=This can occur due to associated left ventricular hy pertrophy and because of limited cardiac output to the coronary arteries due to the obstruction.&var233=True&var232=Although aortic regurgitation may develop an d progress with time in the absence of endocarditis, sub-aortic obstruction does predispose to bacterial endocarditis, so the appearance of a new murmur should raise this possibility.&var231=True&var230=Subaortic membranes may recur and the refore continued follow up is necessary, and recurrent murmurs should be investi gated.&var229=False&var228=Subaortic stenosis may progress as the membrane grows and the murmur will become louder until the obstruction is so severe that the c ardiac output is reduced.&var227=True&var226=Although the murmur of aortic steno sis is best heard at the upper left sternal edge, that of sub-aortic stenosis is loudest lower on the chest.&var225=False&var224=Aortic regurgitation is present echocardiographically in 50% of cases of sub-aortic stenosis.&var223=True&var22 2=The murmur is loudest at the lower left sternal edge and may have a similar qu ality to a VSD.&var221=True&var220=A systolic murmur heard at the apex is due to mitral regurgitation.&var219=False&var218=Because the VSD is unrestrictive, and the ventricular pressures are equal, there is no VSD murmur in tetralogy. The m urmur is due to sub-pulmonary and pulmonary stenosis.&var217=False&var216=This i s because VSDs, particularly muscular ones, tend to undergo spontaneous closure. &var215=True&var214=Particularly in young babies, a large VSD may be associated with a delay in fall of the pulmonary vascular resistance and little or no systo lic murmur.&var213=False&var212=Small muscular VSDs may have very soft murmurs i n a very precise location relating to the position of the VSD in the septum.&var 211=True&var210=VSDs in general have a tendency to get smaller with time and som e undergo complete spontaneous closure.&var209=False&var208=Very large VSDs may not be associated with murmurs, and in the setting of pulmonary hypertension the murmur may be soft or absent.&var207=False&var206=Muscular VSDs may close befor e the end of systole leading to a rise in pitch at the end of the murmur. This d oes not happen with perimembranous VSDs.&var205=False&var204=Large VSDs are asso ciated with mitral flow murmurs.&var203=True&var202=The typical murmur of a VSD is a long systolic murmur, although not always pansystolic.&var201=True&var200=T hey are rare after puberty.&var199=True&var198=Innocent vibratory murmurs may be quite widespread on the precordium, although loudest at the lower left sternal edge, but they do not radiate to the back.&var197=False&var196=Sub-aortic stenos is produces a murmur at the lower left sternal edge, and on occasions this may b e vibratory in quality.&var195=False&var194=They are best heard at the lower lef t sternal edge.&var193=False&var192=Innocent vibratory murmurs occur in early sy stole.&var191=False&var190=Although innocent vibratory murmurs may be 3/6 in int ensity, the presence of a thrill indicates a pathological murmur.&var189=True&va r188=Although the presence of symptoms which could be cardiac must provoke a car

eful search to exclude heart disease, the prevalence of innocent murmurs means t hat they may co-exist with a non-cardiac cause of breathlessness.&var187=False&v ar186=There are several theories about the origins of innocent murmurs but none has been proven.&var185=False&var184=They also vary with position and if the pat ient is anxious.&var183=True&var182=The peak incidence of innocent murmurs is fr om 3 years to adolescence.&var181=False&var180=Pulmonary regurgitation can occur with a very dysplastic, or completely absent pulmonary valve, in which case the second heart sound is singular.&var179=True&var178=Severe chronic pulmonary reg urgitation will lead to right heart failure and elevation of the jugular venous pressure.&var177=True&var176=Because tetralogy of Fallot is associated with an a bnormal pulmonary valve which may be very dysplastic, repair often leads to pulm onary regurgitation.&var175=False&var174=Because the pitch of the murmur depends on the diastolic pressure in the main pulmonary artery, pulmonary regurgitation in pulmonary hypertension may be the same pitch as aortic regurgitation.&var173 =True&var172=A dilated main pulmonary artery may be the only abnormality on ches t X-ray.&var171=True&var170=Mild pulmonary regurgitation is well tolerated and m ay never become symptomatic.&var169=False&var168=One study found 42% of 6- to 11 -year-olds had trivial to moderate pulmonary regurgitation on colour flow mappin g.&var167=False&var166=If bronchopulmonary disease leads to an elevated pulmonar y artery pressure, pulmonary regurgitation may develop through a previously norm al valve, or associated with pulmonary artery dilatation.&var165=True&var164=Lik e aortic regurgitation the predominant murmur is diastolic, although a systolic murmur may coexist due to increased right ventricular output due to the regurgit ation, or due to coexistent pulmonary stenosis.&var163=False&var162=Pulmonary re gurgitation is much more common in association with tetralogy of Fallot, or afte r surgical treatment of pulmonary stenosis.&var161=False&var160=The occurrence o f sub-pulmonary stenosis as part of tetralogy of Fallot makes the muscular form more common.&var159=True&var158=Sub-pulmonary stenosis may be due to muscular hy pertrophy, in which case it can be dynamic and lead to cyanotic 'spells' which m ay be life threatening. &var157=False&var156=The increased dynamic sub-pulmonary stenosis allows flow for a shorter time in systole.&var155=True&var154=Because the murmur arises from below the valve, it is loudest at the mid left sternal ed ge.&var153=False&var152=Cyanotic spells occur because of increasing dynamic subpulmonary stenosis, with decreased flow across the lesion and a softer or absent murmur.&var151=False&var150=Right ventricular hypertrophy associated with valva r pulmonary stenosis may lead to added subvalvar stenosis.&var149=True&var148=In association with a ventricular septal defect, for example in tetralogy of Fallo t, if the stenosis is severe there will be right to left shunting across the ven tricular septal defect.&var147=True&var146=It is systolic and may end before the second heart sound.&var145=False&var144=The murmur is heard in the same place a nd the pitch may be similar. They can be distinguished if the sub-pulmonary sten osis murmur radiates to the back.&var143=True&var142=Subvalvar pulmonary stenosi s usually occurs associated with a VSD or as part of tetralogy of Fallot.&var141 =False&var140=Mild to moderate aortic regurgitation may be present for many year s before symptoms develop.&var139=False&var138=The aortic dilatation of Marfan s s yndrome may lead to leakage through an anatomically normal valve.&var137=True&va r136=There is a male preponderance because congenital abnormalities of the aorti c valve are more common in males.&var135=False&var134=In mild aortic regurgitati on the apex beat may be normal. In acute severe aortic regurgitation (such as as sociated with endocarditis) the left ventricle may be unable to dilate to accomm odate the regurgitant fraction and the cardiac output falls.&var133=False&var132 =The regurgitation in diastole leads to a drop in diastolic pressure. This adapt ation is not present in acute aortic regurgitation.&var131=True&var130=The murmu r of aortic regurgitation is diastolic, although there may be an associated syst olic murmur due to the increase is left ventricular output.&var129=False&var128= A congenitally abnormal aortic valve is more likely to develop endocarditis than a normal one. The resulting aortic regurgitation may be acute and severe.&var12 7=True&var126=Aortic regurgitation may occur after surgical or balloon aortic va lvotomy.&var125=True&var124=If there is aortic root dilatation, for example in M arfan s syndrome, a normal aortic valve may leak.&var123=True&var122=If the onset

is acute, there may be low cardiac output and therefore no murmur.&var121=False& var120=A patent duct may be useful in the setting of complex congenital heart di sease and may be maintained with prostin.&var119=True&var118=The murmur comes fr om turbulent flow across the duct so if there is no restriction to flow, and par ticularly in neonates with elevated pulmonary artery pressure, there may be no m urmur.&var117=True&var116=An audible patent ductus arteriosus has one of the hig hest rates of endocarditis and this is an indication of closing these ducts.&var 115=False&var114=The presence of a mitral diastolic murmur indicates a heavy lef t to right shunt and so a medium or large duct.&var113=False&var112=These ducts may close spontaneously with time, but may require active treatment if the baby is symptomatic.&var111=True&var110=The lower resistance of the pulmonary bed lea ds to a shunting in diastole and a low diastolic blood pressure.&var109=True&var 108=Continuous murmurs cross the second heart sound but are not present for the whole of the cardiac cycle.&var107=False&var106=If pulmonary hypertension develo ps, the murmur will become shorter and quieter.&var105=True&var104=If loud it ma y be heard throughout the precordium and at the back.&var103=True&var102=Althoug h this description only applies to moderate sized ducts with a large pressure dr op across them. It is therefore not usual in neonates or if pulmonary hypertensi on supervenes.&var101=True&var100= &var99=True&var98=The presence of a thrill or heave indicates a pathological murmur.&var97=False&var96= &var95=True&var94=An ejection click would indicate the presence of an abnormal pulmonary valve.&var93 =False&var92=They are loudest in the pulmonary area.&var91=False&var90=A murmur that radiates to the back is almost always pathological.&var89=False&var88=Indee d in some children they may not be present when the child is well.&var87=True&va r86=But they may also be normal in the presence of mild to moderate pulmonary st enosis.&var85=True&var84=The presence of wide splitting indicates an ASD. This c an be a difficult sign to elicit.&var83=True&var82=Because innocent murmurs are so common in childhood, some children with non-cardiac symptoms will have an inc idental unrelated murmur. &var81=False&var80=Mild pulmonary stenosis is well tol erated and may never progress to more severe disease.&var79=False&var78=Even wit h moderate stenosis these investigations may be normal.&var77=True&var76=Any con dition which increases the cardiac output, such as pregnancy, a febrile illness or exercise, may result in the murmur becoming louder.&var75=True&var74=The sten osis murmur is systolic. A diastolic murmur may come from associated pulmonary r egurgitation.&var73=False&var72=The position of the murmur gives a clue to the d iagnosis.&var71=True&var70=Severe pulmonary stenosis may be associated with smal l pulmonary arteries and an abnormal pulmonary valve may be associated with dila tation of the pulmonary artery without significant stenosis.&var69=False&var68=B icuspid or mildly abnormal valves may click but not be significantly narrow and so not generate a murmur.&var67=True&var66=This is due to decreased pulmonary bl ood flow and right to left shunting at atrial level but may be mild while the PD A is open.&var65=True&var64=Mild pulmonary stenosis is usually asymptomatic.&var 63=False&var62=Although this is true up to a point, with very severe stenosis th e cardiac output falls and the murmur becomes quieter.&var61=False&var60=The pul monary artery may appear prominent in the setting of a large shunt, and the asce nding aorta may be relatively inconspicuous.&var59=False&var58=With elevated dia stolic pulmonary artery pressure, the pulmonary valve may become regurgitant.&va r57=True&var56=Primum atrial septal defect (partial atrioventricular septal defe ct) is commonly associated with regurgitation of the left or right atrioventricu lar valves, leading to murmurs that are more easily heard than those of a simple secundum atrial septal defect. Primum atrial septal defect is also more common in patients with trisomy 21 and therefore may be detected as the result of routi ne screening.&var55=True&var54=A superior axis is more typical of a primum ASD ( partial atrioventricular septal defect).&var53=False&var52=There may be generous right ventricular voltages on ECG due to right ventricular dilatation, but in g eneral if there is right ventricular hypertrophy then pulmonary hypertension nee ds to be suspected.&var51=True&var50=Pulmonary hypertension due to an atrial sep tal defect does not tend to occur until the fourth or fifth decade of life, and may not be present even in older patients. Patients with primary pulmonary hyper tension may maintain an atrial communication as this helps cardiac output.&var49

=False&var48=Tricuspid diastolic murmurs tend to be associated with larger defec ts.&var47=True&var46=With larger defects there is more flow and the split become s wider.&var45=True&var44=The splitting of the second sound is widened in an atr ial septal defect but it may still be variable, particularly in smaller defects. &var43=False&var42=The murmur comes from increased flow across the pulmonary out flow tract.&var41=False&var40=Although it is postulated that the noise originate s from the internal jugular vein being distorted by the spinous process of a ver tebra this is not proven.&var39=False&var38=A loud PDA murmur is sometimes heard at the back.&var37=False&var36=This has been described.&var35=True&var34=Also d uring pregnancy or in the presence of anaemia.&var33=True&var32=It confirms the diagnosis.&var31=True&var30=They are usually louder on the right.&var29=False&va r28=Although generally they are lower pitched than PDA murmurs.&var27=True&var26 =They are loudest when sitting and may disappear on lying flat.&var25=False&var2 4=They are continuous, through systole and diastole.&var23=False&var22=They are common in children and young adults.&var21=True&var20=This is particularly true on exercise.&var19=True&var18=This may occur during childhood with growth. Occas ionally valves which are predominantly regurgitant may progress with calcificati on and fibrosis to become predominantly stenotic.&var17=True&var16=Although usua lly the ECG will show LVH with important aortic stenosis, it may be normal.&var1 5=True&var14=A loud aortic component of the second sound occurs with a mobile va lve and moderate stenosis. As the valve becomes less mobile, the second heart so und may become soft or single.&var13=True&var12=The apex beat may be tapping in quality, but the thrill is best felt at the upper right sternal edge and suprast ernal notch. Occasionally in infants, the thrill may be to the left of the stern um, but moves to the right with growth.&var11=False&var10=The later the peak of the murmur, the more severe the stenosis.&var9=True&var8=Aortic root dilatation may occur in the presence of a bicuspid aortic valve without significant stenosi s.&var7=False&var6=Because this occurs in left ventricular failure.&var5=True&va r4=Although this may disappear if the valve becomes very immobile.&var3=True&var 2=The male:female ratio is about 4:1.&var1=False