To-and-fro murmur in the young due to major congenital cardiac defects: is cardiac auscultation obsolete?

Dear Sir, Cardiac auscultation is becoming a dying clinical art. The balance between cardiac physical examination and imaging modalities in the diagnosis and delineation of congenital cardiac disease has changed significantly since the introduction of echocardiography, and more recently computed tomography, and magnetic resonance imaging, and is now leaning towards a mechanistic approach while the art of cardiac examination is losing its pivotal role. To-and-fro murmur in the young emphasises the importance of cardiac auscultation. It comprises a lowpitched crescendo decrescendo systolic component and a decrescendo diastolic component with a short pause between the two, best heard at the mid-left parasternal border. Its presence indicates a major congenital cardiac defect and requires initiation of intensive cardiorespiratory monitoring in an intensive care unit setting as well as prompt diagnostic evaluation. The differential diagnosis must include the following major cardiac lesions: aortic-left ventricular tunnel (Fig 1), absent pulmonary valve syndrome (Fig 2), and truncus arteriosus with truncal valve incompetence (Fig 3). The aortic-left ventricular tunnel may be confused with other more common lesions as the coronary artery-left ventricle fistula and ruptured sinus of Valsalva (Fig 4). These lesions can occur in infants but have a diphasic murmur, often without the characteristic pause. The echocardiographic evaluation of children with coronary artery fistula reveals normal coronary artery anatomy. Both transthoracic and transoesophageal echocardiography reveal the aneurismal dilatation associated with the ruptured sinus of Valsalva, the site of rupture, and the length of the diverticulum. Ventricular septal defect with aortic regurgitation is associated with a to-and-fro murmur but is rare in young children. Echocardiographic evaluation of congenital absence of the pulmonary valve permits visualisation of the anterior misaligned ventricular septal defect with overriding aorta and a