PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1237

Echocardiography in Healthy Children

To the Editor.

Steinberger and colleagues' article, "Echocardiographic Diagnosis of Heart Disease in Apparently Healthy Adolescents," raises several questions.¹

One of the questions is why none of the children had abnormal findings on an examination by a board-certified pediatrician when 6 of the children had murmurs. The 2 children with atrial septal defects had systolic and diastolic murmurs and split second sounds. The child with a bicuspid aortic valve had an ejection click and a murmur in the aortic area. It could be argued that any well-trained primary care physician should be able to detect such murmurs, and that in training it is just as important to be able to ausculate a heart as to look at a tympanic membrane. One possible reason why these lesions were undetected is that the children may not have received the periodic examinations that constitute an important part of child health care.

Another question is whether the lesions detected represent serious cardiac disease. Mitral valve prolapse without redundant thickened leaflets is considered by some cardiologists to be a normal variant with no risk of increased adverse effects compared to individuals without prolapse.^2,3 Bicuspid aortic valves are found in up to 2% of the population⁴ and echocardiographic mitral regurgitation is found in up to 46% of the population.⁵ Neither of the 2 children with bicuspid aortic valves nor the child with the small patent ductus would have any symptoms from these lesions, and the only justification for the detection would be to prevent bacterial endocarditis after dental procedures. However, there is no clear evidence that prophylactic antibiotics before a dental procedure actually prevents bacterial endocarditis.^6,7 Four of 6 patients with congenital heart disease developed endocarditis despite prophylactic antibiotics in the Pittsburgh Children's Hospital study.⁸ Physicians should continue to follow American Heart Association (AHA) recommendations for endocarditis prevention,⁹ but detecting minor lesions in children with no clinical findings may not lead to a reduction in the number of cases of endocarditis and certainly would not be cost-effective.

It is also unclear in the article whether there would be any clinical benefit to the children with left pulmonary artery stenosis, cardiomyopathy, and pulmonary hypertension because there is not enough information regarding the cause or severity of these conditions.

The conclusion from Steinberger's article should be to train our primary care clinicians to perform a competent cardiac examination and appropriately refer patients to a pediatric cardiologist. The clinical need to identify cardiac abnormalities only detectable by echocardiography remains unclear.

Ernest G. Brookfield
Mercy Children's Hospital
Division of Pediatric Cardiology
Toledo, OH 43608

REFERENCES

1. Steinberger J, Moller JH, Berry JM, Sinaika AR Echocardiographic diagnosis of heart disease in apparently healthy adolescents. Pediatrics. 2000; 105:815-818 [Abstract/Free Full Text]
2. Freed LA, Prevalence and clinical outcome of mitral valve prolapse. N Engl J Med. 1999; 341:1-7 [Abstract/Free Full Text]
3. Nishimana RA, McGoon MD N Engl J Med. 1999; 341:1-3
4. Fyler DC. Aortic outflow abnormalities. Nadas' Pediatric Cardiology. St Louis, MO: Mosby Yearbook, Inc; 1992:510
5. Snider AR, Server GA. Echocardiography in Pediatric Heart Disease. St Louis, MO: Mosby Yearbook, Inc; 1990:60
6. Strom B, Dental and cardiac risk factors for infective endocarditis; a population-based, case-control study. Ann Intern Med. 1998; 129:761-769 [Abstract/Free Full Text]
7. Durack DT Antibiotic for prevention of endocarditis during dentistry: time to scale back? Ann Intern Med. 1998; 129:829-830 [Free Full Text]
8. Martin JM, Neches WH, Wald ER. Infective endocarditis: 35 years of experience at a children's hospital. Clin Infect Dis. 1997;669-675
9. Dajani AS, Tawbert KA, Wilson W, Prevention of bacterial endocarditis; recommendations by the American Heart Association. JAMA. 1997; 277:1794-1801 [Abstract/Free Full Text]

In Reply.

We thank Dr Brookfield for his response to our manuscript,¹ and we agree that a well-trained primary care physician should be able to detect prominent findings on cardiac examination. Nevertheless, these findings were not detected in our group of children who received standard health care. Although it is possible that primary physicians may lack sufficient training in cardiac auscultation, it is also possible that they lack sufficient time for detailed examination of an asymptomatic child, under our current system of health care.

All 4 of our patients with mitral valve abnormalities had anatomically abnormal valve, ie, prolapsing, myxomatous, and/or thickened mitral valves, with mild (1+), persistent insufficiency. We believe that these mitral valves were structurally and functionally abnormal and met the criteria for bacterial endocarditis prophylaxis recommended by the current AHA guidelines.^2-6 Detection and follow-up of the bicuspid aortic valve found in 2 of our patients are important because the valves tend to become stenotic and/or regurgitant over time, even if at the time of diagnosis they are functionally normal and the patient is asymptomatic. Although the cost-effectiveness of infective endocarditis prophylaxis in a functionally normal bicuspid aortic valve remains debatable, in a litigious health care environment, we chose to follow the current AHA guidelines and recommend endocarditis prophylaxis in these patients.

Pulmonary hypertension and cardiomyopathy are believed to be progressive conditions. Therefore, it is difficult to dismiss their importance at the time of diagnosis even in the absence of symptoms. Follow-up of these children with the expectation of obtaining more information and possibly early intervention in the future seems reasonable.

In conclusion, as stated in our article, we do not propose undirected echocardiography as a screening method for cardiac abnormalities in children. We and others⁷ have shown that asymptomatic cardiac disease with present and potential future functional significance remains undetected by current screening methods. Therefore, we propose a reevaluation of the current methods of screening, and increased emphasis on the training of physicians in the skills of auscultation.

Julia Steinberger
James H. Moller
James M. Berry
Alan R. Sinaiko
University of Minnesota Hospitals and Clinics
Division of Pediatric Cardiology
Minneapolis, MN 55455

REFERENCES

1. Steinberger J, Moller JH, Berry JM, Sinaiko AR Echocardiographic diagnosis of heart disease in apparently healthy adolescents. Pediatrics. 2000; 105:815-818
2. Carabello BA Mitral valve disease. Curr Probl Cardiol. 1993; 7:423-478
3. Devereux RB, Hawkins I, Kramer-Fox R, Complications of mitral valve prolapse. Am J Med. 1986; 81:751-758 [CrossRef][Medline]
4. Danchin N, Briancon S, Mathieu P, Mitral valve prolapse as a risk factor for infective endocarditis. Lancet. 1989; 1:743-745 [Medline]
5. Devereux RB, Frary CJ, Kramer-Fox R, Roberts RB, Ruchlin HS Cost effectiveness of infective endocarditis prophylaxis for mitral valve prolapse with or without a regurgitant murmur. Am J Cardiol. 1994; 74:1024-1029 [CrossRef][Medline]
6. Dajani AS, Taubert KA, Wilson W, Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA. 1997; 277:1794-1801
7. Goldberg SJ, Donnerstein RL, Samson RA Accuracy of diagnosis by history and physical examination in a pediatric cardiology clinic compared to echocardiography. Circulation. 1998; 17:I-187