Download - Pulmonic Valve Disease
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Pulmonic Valve Disease
Bernardo D. Morantte Jr. M.D.Dept. of Medicine
College of MedicinePamantasan Ng Lungsod Ng Maynila
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Pulmonic Valve Disease
Pulmonic regurgitation is the back flow of blood from the pulmonary artery into the right ventricle during diastole. It is more often seen in the adult population
Pulmonic stenosis is the obstruction in the systolic flow of blood from the right ventricle to the pulmonary artery.
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Pathophysiology of Pulmonic Regurgitation
Pulmonic regurgitation causes right ventricular and eventually also right atrial dilatation.
Secondary dilatation of the tricuspid annulus results in tricuspid regurgitation
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Pathophysiology of Pulmonic Regurgitation
Right HeartRA
RV
PA
Tricuspid valve
Pulmonic valve
Red Arrow = regurgitant jet
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Etiology of Pulmonic Regurgitation
Pulmonary hypertension of whatever etiology is the most frequent cause of pulmonic regurgitation such as:
Chronic obstructive lung disease Large Pulmonary emboli Left sided valvular diseases such as: MS. MR, AS, AR Idiopathic pulmonary hypertension Bacterial endocarditis Marfan’s syndrome After balloon valvulotomy for pulmonic stenosis
and repair of Tetralogy of Fallot
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Symptoms
Symptoms related to the primary disease such as dyspnea, orthopnea / PND, cough, wheezing, chest pain
Right upper abdominal quadrant pain
due to hepatomegaly
Peripheral edema
Fever in endocarditis
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Physical Examination
Key finding: the presence of low to high pitched early diastolic murmur at the 2nd left intercostal space ( Graham Steele murmur) which increases on inspiration.
Signs of Pulmonary hypertension P2, sternal lifting, subxyphoid pulsation due to RV dilatation, right sided S3
Other findings: Neck vein distention Hepatomegaly Ascites and Peripheral edema
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Diagnostics
EKG _ RV and RA hypertrophy
Chest x-ray *Dilated PA *Prominent right heart border *Obliteration of the retrostrernal space in the left lateral view due to dilated RV
*Evidence of pulmonary disease
V/Q lung scan when pulmonary emboli is suspected.
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Echocardiography
Key Finding: On doppler, a regurgitant jet is present below the pulmonic valve. Elevated pulmonary pressures
RV and PA dilatationOther findings depending on etiology such as: bacterial vegetations on the pulmonic valve, congenital anomalies
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Medical Therapy
Treatment of the underlying cause or pulmonary disease may alleviate the pulmonary hypertension and reduce the degree of pulmonic regurgitation
Treatment for CHF
Diuretics
Digoxin
Vasodilators
SBE prophylaxis
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Surgical Therapy
Pulmonic valve replacement
Pulmonic valve replacement is rarely indicated unless medical therapy fails to improve the symptoms of right heart failure.
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Etiology of Pulmonic Stenosis
Congenital_ 95% of cases a. Isolated _ valvular, infundibular, supravalvular b. With other anomalies such as: Tetralogy of Fallot, Noonan’s syndrome, double outlet right ventricle
Carcinoid syndrome
In born errors of metabolism such as mucopolysaccharoidosis, Homocystinuria
Rheumatic heart diseaseConnective tissue diseases
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Pathophysiology of Pulmonic StenosisRight Heart
RA
RV
PA
Tricuspid valve
Pulmonic valve
Red arrow = regurgitant jet
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Diffferential DiagnosisBenign pulmonic flow murmur
the murmur is usually short and gr I-II / VI in intensityAtrial septal defect
Fixed wide splitting of S2 Prominent pulmonary arterial vasculature in the chest x-ray suggesting the presence of a left to right shunt.
VSD
blowing holosystolic murmur is usually heard along the left lower sternal border
Aortic stenosis the murmur is in the aortic area (2nd RICS): paradoxical splitting of S2
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Symptoms
Isolated pulmonic stenosis maybe asymptomatic if pressure gradient across the pulmonic valve is < 40 mm Hg
Easifatigability
RUQ pain due to hepatomegaly
Edema
palpitations
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Physical examination
Key finding: Gr III-IV / VI harsh crescendo-decrescendo systolic murmur at the 2nd LICS which increases on inspiration
S1 with systolic ejection click
P2, Right sided S4 present
Jugular venous distention with prominent A
Hepatomegaly
Peripheral edema
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Diagnostics
EKG_ RVH with strain pattern, RAH
Chest x-ray :
Dilated or prominent PA
Obliterated retrosternal space in
the left lateral view
Prominent right heart border
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Echocardiogram
Key finding: On doppler an increase in velocity across the pulmonic valve which indicates the presence of a pressure gradient
RVH and dilatation
RA dilatation
Pulmonic valve may appear deformed and rigid
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Cardiac Catheterization
Not indicated for diagnosis; maybe performed if other congenital anomalies are suspected
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Medical Therapy
Asymptomatic patient only SBE prophylaxis is requiredTreatment for right sided CHF
Diuretics Digoxin
Balloon valvulotomy for symptomatic patient with pressure gradient of > 40 mm
* Repeat valvulotomy in 11% of patients in 10 years
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Surgery
Pulmonic valve replacement for dysplastic valve with severe stenosis, in Tetralogy of Fallot, and after repair of the Tetralogy
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