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Pulmonary Regurgitation

Pulmonary regurgitation can be caused by dilation of the pulmonary valve ring from pulmonary hypertension or dilation of the pulmonary artery. It may also result from endocarditis, surgery for congenital pulmonary stenosis or tetralogy of Fallot, or congenital valve anomalies. Patients typically present with right ventricular volume overload and eventually pulmonary hypertension leading to right ventricular failure. On physical exam, they have a hyperdynamic right ventricle and enlarged pulmonary artery. Echocardiography and cardiac MRI can assess the severity by evaluating the valve, right ventricle size, and pulmonary regurgitation jet characteristics. Treatment involves addressing the underlying cause of pulmonary hypertension to alleviate the regurgitation.

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74 views3 pages

Pulmonary Regurgitation

Pulmonary regurgitation can be caused by dilation of the pulmonary valve ring from pulmonary hypertension or dilation of the pulmonary artery. It may also result from endocarditis, surgery for congenital pulmonary stenosis or tetralogy of Fallot, or congenital valve anomalies. Patients typically present with right ventricular volume overload and eventually pulmonary hypertension leading to right ventricular failure. On physical exam, they have a hyperdynamic right ventricle and enlarged pulmonary artery. Echocardiography and cardiac MRI can assess the severity by evaluating the valve, right ventricle size, and pulmonary regurgitation jet characteristics. Treatment involves addressing the underlying cause of pulmonary hypertension to alleviate the regurgitation.

Uploaded by

Tania
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PULMONARY REGURGITATION

ETIOLOGIES

- Dilatation of valve ring secondary to pulmonary hypertension or dilation of pulmonary artery


- Endocarditis
- Surgical treatment of congenital PS
- Surgical treatment of Tetralogy of Fallot
- Congenital valve anomaly: absent, malformed, fenestrated or supernumerary leaflets
o Associated with TdF, VSD, PS
- Rare: trauma, carcinoid, rheumatic involvement, injury due to PA catheter, syphilis

CLINICAL PRESENTATION

- Isolated PR cause RV volume overload


- Complicated eventually by pulmonary hypertension = RV failure
- Septic pulmonary emboli and pHTN in endocarditis

PHYSICAL EXAM

- RV Hyperdynamic – palpable systolic pulsations in left parasternal area, lift


- Enlarged PA – systolic pulsations of 2nd left intercostal space
- Auscultation
o éP2 2nd to pulmonary hypertension
§ Absent in congenital absence of pulmonary valve
o Wide split of S2
o Nonvalvular systolic ejection click 2nd pulmonary artery expansion – midsystolic murmur in
2nd LICS
o S3 and S4 in 4th LICS, ↑ with inspiration
o Diastolic murmur without pHTN
§ Low pitch
§ 3-4th LICS, near sternum
§ 0,04s after P2
§ ↑ with inspiration
o Graham-Steel murmur: annular dilation 2nd to pulmonary HTN (PAPs > 55 mmHg)
§ High pitch
§ Decrescendo
§ After P2
§ 2-4th LICS
§ Loud P2 or fused S2
§ Ejection sound
§ Systolic murmur of TR
§ Low frequency presystolic murmur (flow across tricuspid valve – rare)
§ ↑ Inspiration
§ ↓ Valsalva

ELECTROCARDIOGRAPHY

Marie-Jeanne Bertrand MD M.Sc - 2015 1  


- RV diastolic overload (rSr or rsR in precordial leads)
- RV hypertrophy in presence of pulmonary hypertension

CHEST X-RAY

- Enlarged PA
- Enlarged RV

ECHOCARDIOGRAPHY

- Doming of the leaflet


- Hypoplasia, dysplasia or absence of the valve
- Dilatation of the pulmonary artery, RA, RV
- In absence of pulmonary hypertension, systolic dysfunction and dilatation of RV is an indirect sign of
significant pulmonary regurgitation (volume overload)

★ Suggested reference: Zoghbi W. et al. Recommendations for the evaluation of the severity of native valvular
regurgitation with two-dimensional and Doppler echocardiography. 2003 J Am Society
Echocardiography;16:777-802.

Mild Moderate Severe

Pulmonary valve Normal Normal of abnormal Abnormal


RV size Normal Normal of dilated Dilated
Large, wide origin and brief
Jet size by color Doppler Thin Intermediate
duration
Dense, steep deceleration, early
Jet density - CW Soft, slow deceleration Dense
termination of diastolic flow
Pulmonary systolic flow - PW Slightly increased Intermediate Increased

★ Suggested reference: Nishimura R. A. et al. 2014 ACC/AHA guidelines for the management of patients with
valvular heart disease. J Am Coll Cardiol 2014;63:e57-185 – table 21

CMR: important role – PA dilation, quantify PR severity, RV dilation and systolic function

MANAGEMENT

-­‐ PR alone requires specific treatment


-­‐ PVR – pulmonary allograft is preferred
-­‐ Treat underlying cause of pulmonary HTN – will ameliorate the PR

Marie-Jeanne Bertrand MD M.Sc - 2015 2  


Content of this summary from these references:
• Otto C & Bonow R. Valvular Heart Disease. (2012) In Bonow R. et al. Braunwald’s Heart Disease, 9th
edition, pp. 1468-1539. Philadelphia, PA: Elsevier.
• Nishimura R. A. et al. 2014 ACC/AHA guidelines for the management of patients with valvular heart
disease. J Am Coll Cardiol 2014;63:e57-185.
• Zoghbi W. et al. Recommendations for the evaluation of the severity of native valvular regurgitation
with two-dimensional and Doppler echocardiography. 2003 J Am Society Echocardiography;16:777-
802.

Marie-Jeanne Bertrand MD M.Sc - 2015 3  

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