A common problem is a soft basal ejection murmur in an asymptomatic child with a normal electrocardiogram and chest x-ray films. If the diagnosis is aortic stenosis, there is a need for prophylaxis for subacute bacterial endocarditis and concern about development of calcific aortic stenosis. In 40 consecutive children referred for this differential diagnosis, aortic stenosis was diagnosed in 30, based on an ejection murmur at the second right interspace (not necessarily louder than at the second left), which transmitted well to the neck, accompanied by a normal second heart sound. Pulsed Doppler echocardiography confirmed turbulence at the aortic valve in 26. In the 10 children diagnosed clinically as having an innocent murmur, three had evidence on pulsed Doppler echocardiography for an abnormal aortic valve. The conventional echocardiographic findings of an eccentric aortic orifice were present in only 21 of 29 patients with aortic turbulence. Though our current clinical criteria are reasonably specific (87%), they are not as sensitive (70%). Pulsed Doppler echocardiography provides powerful non-invasive assistance for this important differential diagnosis.
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