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Page 10 of 24 Rao. Vessel Plus 2022;6:22 https://dx.doi.org/10.20517/2574-1209.2021.105

Other atrial level shunts
Sinus venosus and coronary sinus types of ASDs have findings similar to those of ostium secundum ASD in
regard to history, physical examination, ECG, and chest roentgenogram. However, in a large proportion of
patients with sinus venosus ASD, the vector of the P wave is oriented superiorly so that the P wave axis is
between 0° and -90° (left axis deviation of the P wave). 2D echo demonstrates an ASD in the superior
portion of the inter-atrial septum or low in the atrial septum, suggesting sinus venous ASD; this in
contradistinction to secundum ASD in which the defect is situated in the mid inter-atrial septum. In
coronary sinus ASDs, the defect is located close to the coronary sinus. Other defects with features similar to
those of secundum ASD are ostium primum ASD, common atrium, and partial anomalous pulmonary
venous connection (PAPVC). Patients with ostium primum ASD and common atrium exhibit an apical
holosystolic murmur of mitral insufficiency secondary to cleft mitral valve. They also have a distinctive left
axis deviation with frontal plane axis of -30° to -90° (abnormally superior ORS vector). 2D echo will
demonstrate an ASD in the inferior portion of the atrial septum in the primum ASD, whereas the whole
atrial septum is deficient in subjects with common atrium. The mitral cleft and mitral insufficiency can also
be shown in the echo. PAPVC is difficult to differentiate from secundum ASD. PAPVC with intact atrial
septum will exhibit wide but variable splitting of S2. However, careful echo-Doppler studies may identify
the partial veins. Cardiac catheterization and selective cine-angiography may be needed in rare cases.

Functional or innocent murmurs
Functional, normal, or innocent murmurs are frequently heard on routine auscultation of children. Two
such ejection systolic murmurs are precordial vibratory murmur and pulmonary ejection murmur.

The precordial vibratory murmur is also called Still’s murmur. This murmur is best auscultated with the
stethoscope’s bell. It is typically best auscultated at a site in between the apex and lower left sternal border
and does not usually transmit to other sites. Rarely, the murmur may be appreciated widely over the entire
precordial area. The loudness of the murmur is between grades I and III/VI. Characteristically, this Still’s
murmur has musical quality and vibratory character, and is unifrequent. When such a quality of the
murmur is appreciated, one can be certain that the murmur is functional. The vibratory innocent murmur
will diminish with a Valsalva maneuver.

Other findings include normal cardiac impulses, normal cardiac sounds, and normal BP and pulses.
Likewise, the chest X-ray and ECG are normal. Echocardiogram is not necessary, but if performed, it is
normal. Hence, the diagnosis of Still’s murmur is based on auscultatory qualities of the murmur described
above as well as otherwise normal cardiovascular evaluation.

The pulmonary ejection murmur is best auscultated at the LUSB and heard better with the stethoscope’s
diaphragm. The loudness of the murmur varies between grades I and III/VI. The pulmonary ejection
murmur has a higher pitch than the precordial vibratory murmur. This murmur is more notably
appreciated in persons who are of thin build and in patients that have “straight back syndrome”. Other
findings in cardiovascular examination, namely, precordial impulses, heart sounds, BP, and brachial and
femoral pulses, are within normal limits. Chest X-ray, ECG, and echocardiographic studies are also normal.

[17]
[16]
Some investigators have utilized computer-assisted auscultation , piezoelectric sensors , and artificial
intelligence to distinguish functional murmurs from pathologic murmurs.
[18]
Most experienced cardiologists, including the author, do not routinely perform echocardiograms in patients
with the definitive clinical diagnosis of functional or innocent murmurs. However, a recent study found
[19]