Phono-spectrographic analysis of heart murmur in children
© Noponen et al. 2007
Received: 11 November 2006
Accepted: 11 June 2007
Published: 11 June 2007
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© Noponen et al. 2007
Received: 11 November 2006
Accepted: 11 June 2007
Published: 11 June 2007
More than 90% of heart murmurs in children are innocent. Frequently the skills of the first examiner are not adequate to differentiate between innocent and pathological murmurs. Our goal was to evaluate the value of a simple and low-cost phonocardiographic recording and analysis system in determining the characteristic features of heart murmurs in children and in distinguishing innocent systolic murmurs from pathological.
The system consisting of an electronic stethoscope and a multimedia laptop computer was used for the recording, monitoring and analysis of auscultation findings. The recorded sounds were examined graphically and numerically using combined phono-spectrograms. The data consisted of heart sound recordings from 807 pediatric patients, including 88 normal cases without any murmur, 447 innocent murmurs and 272 pathological murmurs. The phono-spectrographic features of heart murmurs were examined visually and numerically. From this database, 50 innocent vibratory murmurs, 25 innocent ejection murmurs and 50 easily confusable, mildly pathological systolic murmurs were selected to test whether quantitative phono-spectrographic analysis could be used as an accurate screening tool for systolic heart murmurs in children.
The phono-spectrograms of the most common innocent and pathological murmurs were presented as examples of the whole data set. Typically, innocent murmurs had lower frequencies (below 200 Hz) and a frequency spectrum with a more harmonic structure than pathological cases. Quantitative analysis revealed no significant differences in the duration of S1 and S2 or loudness of systolic murmurs between the pathological and physiological systolic murmurs. However, the pathological murmurs included both lower and higher frequencies than the physiological ones (p < 0.001 for both low and high frequency limits). If the systolic murmur contained intensive frequency components of over 200 Hz, or its length accounted for over 80 % of the whole systolic duration, it was considered pathological. Using these criteria, 90 % specificity and 91 % sensitivity in screening were achieved.
Phono-spectrographic analysis improves the accuracy of primary heart murmur evaluation and educates inexperienced listener. Using simple quantitative criterias a level of pediatric cardiologist is easily achieved in screening heart murmurs in children.
Although Dr. Laennec's invention, the stethoscope, has been in clinical use for more than 180 years, and electronic stethoscopes with variable amplification gain have been available for over 80 years, it is still difficult to understand auscultation findings [1–3]. The phonocardiogram, first developed in 1894, visualizes auscultatory signals [2, 4, 5]. The spectral phonocardiogram has proven to be a reliable tool that gives information of whether or not the murmur is pathological. Based on earlier studies and clinical observations, it has been assumed that pathological murmurs involve sounds of higher frequency [2, 5]. Phonocardiography and electronic stethoscopy attempt to improve the diagnostic accuracy of cardiac auscultation. In the most recent studies, digital acoustic analysis has demonstrated the validity of these methods [6–11]. Since the 1980's, phonocardiographic research activity had decreased due to the improvements of echocardiography, which yields more visual information. During the past few years, however, the improvements of personal computers have made it possible to design new low-cost, high-quality phonocardiographic devices [12–17]. Spectral phonocardiography emulates the ear and may be ideal for teaching clinical stethoscopy . The phono-spectrogram combines traditional phonocardiogram with time-frequency distribution presentation of the signal. The spectrogram was introduced for heart sound analysis as early as 1955 by McKusik et al, but was afterwards almost forgotten [4, 11].
The first evaluation of children's heart murmur is one of the basic tasks of welfare clinic practitioners and school medical officers. However, based on their frequently limited auscultation experience, they might not be able to recognize the innocence of a heart murmur. Even the auscultation skills of pediatric residents have been found to be suboptimal [18–21]. Several healthy children are referred to pediatric cardiologists or for echocardiography. Parental anxiety may also be a reason to refer the patient for unnecessary examinations, and it is important to recognize an innocent murmur as soon as it is found [22–25]. Auscultation training will naturally improve practitioners' listening skills [26–28].
Previous studies have shown that pediatric cardiologists, based on clinical examination, can differentiate innocent from pathological murmurs with high sensitivity (82...92 %) and specificity (76...99%) [29–33]. Even better results have been attained by using advanced signal processing and pattern recognition tools. Artificial neural network-based screening is reported to have 100% sensitivity and specificity [13, 14].
The capability of a doctor or a computerized system to differentiate between pathological and innocent murmurs depends on the quality of the pathological murmurs. It is easy to recognize loud murmurs as pathological by means of clinical or digital analysis . Serious defects are seldom missed, and the challenge is actually to detect mild defects. Small muscular VSD, mild PS or AS causes no hemodynamic harm, but they may require endocarditis prophylaxis. ASD secundum may also be hard to diagnose only by auscultation [34–38].
The purpose of this article was to demonstrate the capabilities of a modern digital system for phonocardiographic recording and analysis and to evaluate its potential for differentiating the characteristic features of heart murmurs in children. Another goal was to investigate how the numerical features measured from a phono-spectrogram can be used to distinguish innocent systolic murmurs from pathological murmurs, which are generally hard to identify in a routine clinical examination. This article additionally concludes more than ten years' experience of studying heart sounds.
Recorded heart sounds
Other innocent musical murmurs
Ventricular septal defect (VSD)
Pulmonary stenosis (PS)
Aortic stenosis (AS) or coarctation (CoA)
Mitral valve defect with (MI) or without leakage
Patent ductus arteriosus (PDA)
Atrial septal defect (ASD)
No murmur (control)
A phonocardiographic system developed in Helsinki University of Technology was used to record heart sounds. The system consisted of an electronic stethoscope and a multimedia laptop computer. A parabolic-shaped cup combined with a high-quality electric microphone and variable-gain battery-powered amplifier in the electronic stethoscope gave a flat frequency response in the whole frequency range of usual heart sounds and murmurs (from 75 to 1500 Hz). The laptop computer had standard multimedia capabilities for audio input and output (16-bit resolution in amplitude, variable recording gain and sampling frequencies from 8 kHz up to 44.1 kHz). Sound signals were recorded digitally using special software for the monitoring and analysis of auscultation. The software was specifically written for this project, and it had several end user (general practitioner) friendly capabilities, such as a database for recordings, basic patient information input dialog, real-time graphical monitoring during recording, selectable and changeable digital filters, tunable settings for the graphical display and analysis, free zooming and replaying of the interesting parts and tools for measuring intensity, duration and frequency range. The software was compatible with standard Microsoft Windows (NT, 2000, XP) environments.
The examiner heard the sounds through earphones and monitored the signals on the computer screen. Thus, the recording was completed in almost the same time as traditional auscultation. Some additional effort was needed to enter the patient information. The new generation commercial electronic stethoscopes were also compatible with this recording program. During the recording it was possible to both to listen to the sound and to follow the phonospectrogram from the display screen, the process was completed often in less than ten minutes.
In the post-analysis phase, the recorded sounds were re-played, and the fingerprints of innocent and pathological heart murmurs were simultaneously examined visually by using a phono-spectrogram. First the recorded sounds were digitally filtered using pass-band filtering (75–1500 Hz) (the 3rd order Butterworth type high-pass and low-pass filters). These filter settings were selected by a long term subjective trials where the objective was to trim the display to show the details of the murmurs as an experienced practitioner would understand them. For the traditional waveform display the signal was scaled by the signal's absolute maximum. The resulted waveform showed the relative intensities of the heart sounds as the ear recognizes them and thus absolute intensity scaling is not needed. Similarly in the spectrogram the intensities were scaled by finding the maximum intensity on the time-frequency distribution and calculating relative intensities in the decibel scale. Thus the value of 0 dB corresponded to the maximum intensity and value of -60 dB, which is almost unbearable to listen to. Short time Fast Fourier Transform (STFT) with Hanning windowing, 512 data samples (46 ms time resolution) and total of 1024 FFT points (10.7 Hz frequency resolution) were used for calculating the spectrogram.
The three most common innocent murmurs, i.e. vibratory murmur, pulmonary ejection murmur and venous hum, and the five most common congenital heart defects, i.e. ventricular septal defect (VSD), aortic valve stenosis (AS), pulmonary valve stenosis (PS), patent ductus arteriosus (PDA) and atrial septal defect (ASD), are presented as examples of the whole data set.
To differentiate between innocent and pathological murmurs, 50 vibratory innocent heart murmurs, 25 innocent pulmonary or aortic ejection murmurs and 50 mild pathological systolic murmurs with intensity equal to or less than grade 3/6 were selected from a larger heart sound database for more detailed analysis. 14 of the selected pathological cases were small VSD, 5 hemodynamically loading ASD secundum, 8 PS with a pressure gradient less than 30 mmHg, 8 AS with a pressure gradient less than 30 mmHg, 3 bicuspid aortic valves with velocity less than 2.0 m/s, 1 mild CoA with a measured 15 mmHg RR difference, 1 hypertrophic cardiomyopathy (HOCM) with a septum thickness of 12 mm but with laminar aortic flow, 5 mitral leakage with or without prolapse (MI) and 3 tricuspid valve leakage (TI).
To find statistically significant parameters, two-tailed heteroscedastic t-test for independent samples was used to calculate the p-values. Three sequential beats were manually selected from each recording. The mean value and standard deviation of the parameters over three beats were calculated. Based on the statistical results, the relative duration of the systolic murmur (percentage of murmur duration out of the interval between the end of S1 and the beginning of S2) and the occurrence of intensive high-frequency components were used as criteria for testing the pathology of the murmur.
The system was able to display and reproduce cardiovascular sound events. The musical murmur caused by harmonic movements of the heart or the vasculature, of which vibratory innocent murmur is a good example, was usually visualized as a well-defined area or line in the spectrogram. Innocent systolic murmur appeared to have a lower peak frequency, below 200 Hz, and shorter duration than pathological murmurs, and it always faded before the second heart sound. The higher the velocity of flow in echogardiography, the more intensive the murmur and the wider the frequency scale. This phenomenon was clearly visible in the spectrogram.
The attached illustrations (Figures from 1, 2, 3, 4, 5, 6, 7, 8) show examples of the most typical murmurs in children. The upper part is a traditional phonocardiogram showing the relative amplitude of the sound. The lower part, i.e. the spectrogram, shows the sound intensity as colors on a frequency scale of 0–1000 Hz. The corresponding intensity scale in decibels is shown on the left. The duration, peak frequency and volume of the murmur were estimated based on a mean of three sequential beats. Volume was compared to the mean of the amplitudes of S1 and S2, obtained from the traditional phonocardiogram.
Mean and standard deviation of patients' ages in the three groups
4.8 ± 3.3
7.3 ± 5.0
6.2 ± 4.9
Duration of S1, S2, systolic murmur and relative duration of systolic murmur
81 ± 15
69 ± 12
100 ± 21
53 ± 12
92 ± 16
75 ± 14
84 ± 36
44 ± 17
87 ± 19
77 ± 17
147 ± 49
78 ± 21
Relative amplitude and low and high frequency limits of systolic murmur
Low freq limit (Hz)
High freq limit (Hz)
23 ± 9
72 ± 15
161 ± 22
20 ± 9
60 ± 9
142 ± 51
30 ± 20
52 ± 19
299 ± 133
Capability of relative length to distinguish between murmurs: sensitivity is 76 % and specificity 84 %
> = 65 %
< 65 %
Capability of high frequency limit to distinguish between murmurs: sensitivity is 88 % and specificity 88 %
> = 190 Hz
< 190 Hz
Combinated criteria: sensitivity 90 %, specificity 91 %
> = 80 % OR > = 200 Hz
Over 90 % of heart murmurs in children are physiological. Moreover, 75 % of them are innocent vibratory murmurs (39, 40, 41, 42). The physician needs to quickly confirm the benign nature of the heart murmur and thus to avoid misdiagnosis [25, 43]. The combination of a spectrogram and a traditional phonocardiogram can be an adequate method for distinguishing innocent murmurs from pathological. When quantitative analysis is used systematically, the clinician should know what signals the system is processing and how. Visual analysis is the first step towards understanding automatic analysis, and it is a more reliable way to classify the findings as pathological or non-pathological than auscultation alone. Interpretation of the spectrogram helps to understand the hemodynamic events and the origin of heart sounds. Laminar flow will cause a harmonic wave movement in surrounding tissues, as exemplified by vibratory murmur with a peak frequency of approximately 150 Hz, which has also been reported in earlier studies [39, 44, 45]. Rapid flow will cause turbulence. The faster the flow velocity, the higher the sound frequencies [4, 5]. These findings are also illustrated by the analysis of aortic stenosis or ventricular septal defect [6–10].
It is not simple to estimate absolute volume of heart sound. The point of maximal intensity of the murmur and the thickness of the chest vary and affects on the intensities of the sound components. In our study, the sound volume of murmur was calculated as a percentage of the volume of murmur compared to the mean volumes of S1 and S2. This may be misleading, as we can see in case 4. The volume of the aortic closure sound is decreased because of valvular stenosis, and the volume of murmur is over estimated compared to auscultation findings.
By analyzing the combined phono-spectrogram, it is possible to achieve the level of an experienced pediatric cardiologist in screening heart murmurs. In this study, by using special criteria, sensitivity of 90 % and specificity of 91% were attained. Both sensitivity and specificity were higher than using phonocradiographic or spectral analysis alone. The results were less good than those obtained in previous studies using the methods of advanced signal processing, pattern recognition and artificial networks [10, 13–15]. In these previous studies, however, the series consisted of pathological cases with distinct and easily recognizable features of heart sounds and murmurs. We agree that it is easy to distinguish fast turbulent flow with a pressure gradient of over 25 mmHg, and in such cases phono-spectral analysis is reliable. We here examined the grey area, i.e. typical physiological cases compared to mildly pathological murmurs, and the most common pitfalls.
Typically, the screening method is allowed to include some false positive cases, but false negatives are unacceptable. In this study, ten (10) small muscular ventricular septal defects, three (3) cases of mild aortic stenosis, one (1) mild peripheral pulmonary stenosis, one (1) mitral valve prolapse with leakage and one tricuspid leakage fell below the 80 % duration criterion. However, each of these cases exceeded the 200 Hz frequency limit. Three (3) atrial septal defects and one (1) slight pulmonary valve stenosis included frequencies below 200 Hz, but each of them was sustained for over 80% of the systolic duration. Five (5) of the pathological murmurs were not caught with either of these two criteria. One (1) of them was a clinically insignificant tricuspid valve leakage, one (1) a very mild mitral valve leakage, one (1) a bicuspic aortic valve without stenosis and one (1) a bicuspic aortic valve with slight stenosis (pressure gradient 16 mmHg). The last and the worst missed pathological murmur was recorded from a three-year-old boy with hypertrophic cardiomyopathy (thickness of ventricular septum 12 mm). Seven out of 75 innocent murmurs exceeded one of the defined screening criteria. None of the ejection murmurs exceeded the 80 % duration limit, and 3 cases exceeded the frequency limit. All of these cases were aortic ejection murmurs with aortic velocity of 1.5–1.8 m/s. Of the vibratory murmurs, one (1) continued for over 80 % of the systolic duration, three (3) contained frequency components of over 200 Hz, but none of them exceeded both limits.
Slight tricuspid leakage is a harmless finding. Mitral valve leakage and bicuspic aortic valve should be recognized because they require endocarditis prophylaxis. The patient with mitral leakage was a fearful retarded boy, and the recorded signal was weak in amplitude, which is why the highest frequencies were missed in the analysis, but the murmur was sustained until the beginning of the second heart sound, implying a pathological finding. The murmurs due to a bicuspic aortic valve without stenosis or with slight stenosis did not differ from the hyperkinetic aortic ejection murmur. The murmur of the patient with hypertrophic cardiomyopathy resembled vibratory innocent murmur . The difference between these murmurs was hardly seen in the spectrogram. Typically, the frequency of vibratory innocent murmur decreases within the systolic interval, while in this case of hypertropic cardiomyopathy it remained constant. The ECG finding was pathological, and the diagnosis was known beforehand. This particular murmur was rather loud, 31% in spectral analysis and 3/6 estimated clinically. However, 10 (20%) of vibratory murmurs were equal to or louder than 30% measured from phonogram.
As the examples show, the method did not recognize hypertrophic cardiomyopathy or mild aortic valve malformation and failed with the mitral leakage, because the recording was suboptimal. We recommend an echocardiography, when the vibratory or aortic ejection murmur is repeatedly found in adolescent age or when the recording is suboptimal. Naturally, young babies need always an echocardiography, because their pulmonary pressure may still be high and the results of heart sound analysis can be misleading.
Modern electronic stethoscopes are suitable for heart sound recording. Visual presentation of the auscultation finding provides an opportunity to study more objectively and quantitatively the timing, quality (frequency contents) and intensity of different heart sound and murmur components and helps us to understand and learn about the hemodynamics of the heart and the origin of cardiac murmurs.
Computer analysis is a powerful tool in teaching an unexperienced listener the art of auscultation [4, 11, 46]. Furthermore, we believe that computer analysis can be a promising new diagnostic method that has a potential to reduce medical costs by eliminating unnecessary referrals, visits to specialists and echocardiograms, especially when the systolic murmur is weak. Recording of auscultation findings also makes teleconsultations possible [47–49] and gives an opportunity to save cardiac or respiratory sounds, phonograms and spectrograms in electronic patient documents.
Phono-spectrographic analysis of heart murmur in children is a useful additional method for the clinical approach and an interesting educational tool as well. The 90 % sensitivity level of the tool may well be at the level of a trained paediatrician. However, it should be considered a single, suboptimal screening tool. As the case of HOCM indicates, ECG and echocardiography are advisable if the intensity of the murmur is fairly high and frequently audible. Patient history and careful physical examination remain the cornerstones in clinical practice.
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