CHAPTER 1. The Heart as a Pump 1 THE CARDIAC CYCLE, 2 Electrical Events in the Cardiac Cycle, 2 Mechanical Events in the Cardiac Cycle, 3 VENTRICULAR FUNCTION, 5 Diastolic Ventricular Filling, 5 Systolic Ventricular Emptying, 5 The Frank-Starling Law, 6 THE CARDIAC VALVES AND PAPILLARY MUSCLES, 8 THE AORTIC PRESSURE CURVE, 9 HEART SOUNDS AND HEART FUNCTION, 11 CIRCULATORY CHANGES AT BIRTH, 11 COMMUNICATIONS BETWEEN SYSTEMIC AND PULMONARY CIRCULATIONS, 14 HEART FAILURE, 15 CHAPTER 2. Sound, Hearing, and the Stethoscope 17 NATURE OF SOUND, 17 HEARING, 19 THE STETHOSCOPE, 21 CHAPTER 3. History and Physical Examination of the Child with Heart Disease 27 HISTORY, 27 Chief Complaint, 27 Prenatal History, 28 Birth and Past Health History, 29 Family History, 32 PHYSICAL EXAMINATION, 32 Inspection, 36 Palpation, 42 BLOOD PRESSURE DETERMINATION, 50 ADDITIONAL DIAGNOSTIC METHODS, 53 Oximetry, 53 Chest X-ray, 54 Two-Dimensional Echocardiography, 54 Doppler Studies, 54 Cardiac Catheterization and Angiocardiography, 55 CHAPTER 4. Phonocardiography and the Recording of External Pulses PHONOCARDIOGRAPHY, 57 ELECTROCARDIOGRAPHY, 58 CAROTID PULSE TRACING, 58 JUGULAR PULSE TRACING, 61 APEX CARDIOGRAPHY, 62 CHAPTER 5. Auscultation Areas, 65 TRADITIONAL AREAS TO AUSCULTATE, 65 REVISED AREAS TO AUSCULTATE, 66 Left Ventricular Area, 67 Right Ventricular Area, 67 Left Atrial Area, 68 Right Atrial Area, 68 Aortic Area, 69 Pulmonary Area, 70 Back and Head, 71 WHERE SHOULD ONE LISTEN? 72 MANEUVERS THAT AID CARDIAC AUSCULTATION, 72 CHAPTER 6. The First Heart Sound (S1), 75 THE ORIGIN OF S1, 75 THE NATURE OF S1, 75 LISTENING FOR S1, 76 SPLITTING OF S1, 77 Normal Splitting of S1, 77 Wide Splitting of S1, 77 INTENSITY OF S1, 78 Extracardiac Factors Affecting S1 Intensity, 78 Cardiac Factors Affecting S1 Intensity, 79 Pathologic Conditions Affecting S1 Intensity, 79 BEAT-TO-BEAT VARIATIONS OF S1, 80 CHAPTER 7. The Second Heart Sound (S2), 83 THE ORIGIN OF S2, 83 THE NATURE OF S2, 84 NORMAL (PHYSIOLOGIC) SPLITTING OF S2, 84 Listening for the Splitting Of S2, 86 ABNORMAL SPLITTING OF S21 86 Persistent Splitting of S2, 87 Wide Persistent Splitting of S2 with Respiratory Variation, 87 Wide Fixed Splitting Of S2, 88 Reversed Splitting of S2, 89 Single S2, 90 AMPLITUDE OF A2 and P2, 91 Loud P2, 91 Loud A2, 92 CHAPTER 8. The Third and Fourth Heart Sounds (S3 and S4), 95 IDENTIFYING EXTRA HEART SOUNDS, 95 THE THIRD HEART SOUND, 96 Origin of S3, 96 Listening for S3, 96 Pathology Associated with S3, 97 THE FOURTH HEART SOUND, 98 Origin Of S4, 98 Listening for S4, 98 Pathology Associated with S4, 99 SUMMATION GALLOP, 99 CHAPTER 9. Other Systolic and Diastolic Sounds, 103 SYSTOLIC CLICKS, 103 Differentiating Clicks from Other Sounds, 103 MIDSYSTOLIC CLICK, 105 Identifying the Midsystolic Click, 105 Echocardiography in the Diagnosis of Mitral Valve Prolapse, 105 Management of Mitral Valve Prolapse, 105 AORTIC EJECTION SOUNDS, 106 Origin and Nature of Aortic Ejection Sounds, 106 Listening for Aortic Ejection Sounds, 107 PULMONIC EJECTION SOUNDS, 107 Origin and Nature of Pulmonic Ejection Sounds, 107 Listening for Pulmonic Ejection Sounds, 107 SYSTOLIC WHOOPS, 108 Origin and Nature of Systolic Whoops, 108 Management of Whoops, 109 OPENING SNAP OF THE MITRAL VALVE, 109 Origin of the Mitral Opening Snap, 109 Listening for the Mitral Opening Snap, 110 Differentiating the Mitral Opening Snap from Other Sounds, 110 OPENING SNAP OF THE TRICUSPID VALVE, 112 Origin and Nature of the Tricuspid Opening Snap, 112 Listening for the Tricuspid Opening Snap, 112 CHAPTER 10. General Characteristics of Murmurs, 113 ORIGIN OF MURMURS, 113 Stenosis, 113 Regurgitation, 114 NATURE OF MURMURS, 114 Timing, 114 Loudness, 115 Pitch and Quality, 118 CHAPTER 11. Systolic Murmurs, 119 CLASSIFICATION OF SYSTOLIC MURMURS, 119 Ejection Murmurs, 119 Regurgitant Murmurs, 119 BENIGN SYSTOLIC MURMURS, 121 Origin of the Benign Systolic Murmur, 121 Nature of the Benign Systolic Murmur, 121 BENIGN EXTRACARDIAC MURMURS, 122 Cervical Venous Hum, 122 Mammary Souffle, 123 Supraclavicular Arterial Bruit, 124 STRAIGHT BACK SYNDROME AND PECTUS EXCAVATUM, 124 Nature of the Murmur of Straight Back Syndrome and Pectus Excavatum, 125 VENTRICULAR SEPTAL DEFECT, 125 Origin of the Murmur of Ventricular Septal Defect, 125 Nature of the Murmur of Ventricular Septal Defect, 126 Additional Findings in Ventricular Septal Defect, 128 Differentiating Ventricular Septal Defect from Other Conditions, 128 Prognosis, 130 MITRAL REGURGITATION, 130 Origin and Nature of the Murmur of Mitral Regurgitation, 130 Causes of Mitral Regurgitation and Insufficiency, 131 TRICUSPID REGURGITATION, 133 Origin and Nature of the Murmur of Tricuspid Regurgitation, 133 Causes of Tricuspid Regurgitation, 134 VALVULAR AORTIC STENOSIS, 134 Origin of the Murmur of Aortic Stenosis, 134 Nature of the Murmur of Aortic Stenosis, 134 Differentiating Aortic Stenosis from Other Conditions, 136 MUSCULAR SUBAORTIC STENOSIS, 138 Origin of the Murmur of Muscular Subaortic Stenosis, 138 Nature of the Murmur of Muscular Subaortic Stenosis, 138 Differentiating Subaortic Stenosis from Other Conditions, 138 SUPRAVALVULAR AORTIC STENOSIS, 139 Origin of the Murmur of Supravalvular Aortic Stenosis, 139 Nature of the Murmur of Supravalvular Aortic Stenosis, 139 PULMONIC STENOSIS, 140 Origin of the Murmur of Pulmonic Stenosis, 140 Nature of the Murmur of Pulmonic Stenosis, 141 Differentiating the Murmurs of Pulmonic Stenosis, 145 Prognosis, 145 DILATATION OF THE PULMONARY ARTERY NEAR THE PULMONARY VALVE, 145 Origin and Nature of the Murmur of Pulmonary Dilatation, 145 ATRIAL SEPTAL DEFECT, 146 Origin of the Murmur of Atrial Septal Defect, 146 Nature of the Murmur of Atrial Septal Defect, 146 Additional Physical Findings in Atrial Septal Defect, 147 Differentiating Atrial Septal Defect from Other Conditions, 147 Prognosis, 148 COARCTATION OF THE AORTA, 148 Origin of the Murmur of Coarctation of the Aorta, 148 Nature of the Murmur of Coarctation of the Aorta, 148 COARCTATION OF THE ABDOMINAL AORTA, 150 CHAPTER 12. Diastolic Murmurs 153 AORTIC REGURGITATION, 153 Nature of the Murmur of Aortic Regurgitation, 154 Additional Clinical Features of Aortic Regurgitation, 154 Differentiating Aortic Regurgitation from Other Conditions, 156 PULMONARY INSUFFICIENCY, 157 Nature of the Murmur of Pulmonary Insufficiency, 157 Differentiating the Murmurs of Congenital and Hypertensive Pulmonary Insufficiency from Other Murmurs, 159 OTHER DIASTOLIC MURMURS, 159 Active Rheumatic Carditis, 159 Inactive Rheumatic Heart Disease with Significant Mitral Regurgitation, 160 MITRAL STENOSIS, 161 Causes of Mitral Stenosis, 161 Origin of the Murmur of Mitral Stenosis, 161 Nature of the Murmur of Mitral Stenosis, 161 TRICUSPID STENOSIS, 164 Nature of the Murmur of Tricuspid Stenosis, 164 Differentiating the Murmur of Tricuspid Stenosis from the Murmur of Mitral Stenosis, 164 CHAPTER 13. Continuous Murmurs 165 TO-AND-FRO MURMURS, 165 PATENT DUCTUS ARTERIOSUS, 166 Diagnosis of Patent Ductus Arteriosus, 166 Nature of the Murmur of Patent Ductus Arteriosus, 167 Additional Physical Findings, 169 Differentiating the Murmur of Patent Ductus Arteriosus from Other Murmurs, 171 Prognosis, 173 PERICARDIAL FRICTION RUB, 173 Origin of the Pericardial Friction Rub, 173 Nature of the Pericardial Friction Rub, 173 Differentiating Pericardial Friction Rub from Other Sounds, 175 OTHER CONTINUOUS MURMURS, 175 Arteriovenous Fistula, 175 Local Arterial Obstruction, 176 CHAPTER 14. Surgically Created Shunts and Prosthetic Valves, 177 SHUNTS, 177 Blalock-Taussig Shunt, 177 Other Shunts, 178 PROSTHETIC VALVES, 179 Bjork-Shiley Tilting Disc Valve, 179 St. Jude Bi-Leaflet Valve, 180 Porcine (Hancock) Heterograft, 180 New Frontiers in Prosthetic Valve Design, 180 EVALUATION OF THE POSTOPERATIVE PATIENT, 181 CHAPTER 15. Complex Anomalies 183 TETRALOGY OF FALLOT, 183 Origin of the Murmur of Tetralogy of Fallot, 183 Nature of the Murmur of Tetralogy of Fallot, 184 Differentiating Tetralogy of Fallot from Other Conditions, 184 Prognosis, 185 PERSISTENT TRUNCUS ARTERIOSUS COMMUNIS, 186 Nature of the Defect, 186; Clinical Features of Persistent Truncus Arteriosus, 186; Nature of the Murmur of Persistent Truncus Arteriosus, 186;  Repair of Persistent Truncus Arteriosus, 187; Prognosis, 188 ENDOCARDIAL CUSHION DEFECTS, 188; Complete Endocardial Cushion Defect, 188; Incomplete Endocardial Cushion Defect, 191; Prognosis, 193; TRICUSPID VALVE ANOMALIES, 193; Tricuspid Atresia, 193; Prognosis, 195; Ebstein's Anomaly, 195; Prognosis, 196 TRANSPOSITION OF THE GREAT ARTERIES, 196; Anatomic Anomalies, 196; Clinical Features, 197; Nature of Heart Sounds and Murmurs in Transposition of the Great Arteries, 198; Prognosis, 198 CORRECTED TRANSPOSITION OF THE GREAT ARTERIES, 198; Anatomic Anomalies, 198; Nature of Heart Sounds and Murmurs in Corrected Transposition of the Great Arteries, 199; Prognosis, 200 HYPOPLASTIC LEFT HEART SYNDROME, 200; Anatomic Anomalies, 200; Clinical Features of Hypoplastic Left Heart Syndrome, 201; Nature of Heart Sounds and Murmurs in Hypoplastic Left Heart Syndrome, 201; Prognosis, 201 TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION, 201; Nature of the Defect, 201; Clinical Features of Total Anomalous Pulmonary Venous Connection, 202; Heart Sounds in Total Anomalous Pulmonary Venous Connection, 202; Prognosis, 202 DOUBLE OUTLET RIGHT VENTRICLE, 203 Nature of the Defect, 203 Clinical Features of Double Outlet Right Ventricle, 203 Heart Sounds in Double Outlet Right Ventricle, 203 Pulmonary Artery Banding, 205 Prognosis, 205 ASPLENIA AND POLYSPLENIA, 205 Asplenia, 205 Polysplenia, 205 Glossary, 209 Transcript for Supplemental CD, 213 Index, 217