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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Diastolic murmur at the left upper sternal border that increases with inspiration

  • Loud pulmonic component of S2

  • Characteristic Doppler echocardiographic findings

GENERAL CONSIDERATIONS

  • Pulmonic regurgitation usually occurs with pulmonary hypertension owing to dilatation of the valve ring

  • Any cause of pulmonic valve ring enlargement can cause regurgitation such as Marfan’s syndrome

  • Primary valve leaflet diseases, such as carcinoid syndrome, rheumatic fever, and endocarditis, can also cause regurgitation

  • It can be the result of prior valvuloplasty for pulmonic stenosis

  • Trivial to mild pulmonic regurgitation is frequently seen on routine echocardiography and is a normal variant

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Patients are usually asymptomatic unless right heart failure occurs

  • Dyspnea and fatigue with moderate to severe regurgitation can occur

  • Palpitations and syncope can occur from ventricular arrhythmias

PHYSICAL EXAM FINDINGS

  • Prominent jugular venous a wave, if pulmonary hypertension is present

  • Right ventricular lift if pulmonary hypertension is present

  • Loud pulmonic S2 if pulmonary hypertension is present

  • Right ventricular S3 and S4 may be heard along the left sternal border

  • In normotensive pulmonic regurgitation:

    • – The diastolic murmur is heard best in the left second or third interspace

    • – It starts after S2

    • – It is medium in pitch

    • – It is increased in intensity with inspiration

  • With pulmonary hypertension:

    • – The diastolic murmur is higher pitched, starts with S2, and is decrescendo (Graham Steell murmur)

    • – It may be confused with the murmur of aortic regurgitation but should get louder with inspiration, unlike an aortic murmur

DIFFERENTIAL DIAGNOSIS

  • Aortic regurgitation

  • Tricuspid stenosis

  • Right heart failure from other causes

DIAGNOSTIC EVALUATION

ELECTROCARDIOGRAPHY

  • Evidence of right ventricular and atrial hypertrophy

IMAGING STUDIES

  • Chest x-ray findings:

    • – Enlargement of the right heart chambers

    • – Peripheral pulmonary vessel absence with enlarged main pulmonary arteries if pulmonary hypertension is present

  • Echocardiography:

    • – Enlarged and hypertrophied right heart chambers

    • – Dilated main pulmonary artery

    • – Possible valve leaflet abnormalities

  • Color-flow Doppler:

    • – Evidence of pulmonary hypertension by increased tricuspid and pulmonic regurgitant velocities

    • – Characteristic regurgitant jet

  • Cardiac MRI provides excellent images of the anatomy and function of the pulmonic valve, right heart chambers, and pulmonary arteries

DIAGNOSTIC PROCEDURES

  • Cardiac catheterization is rarely used to assess pulmonic regurgitation, but may be used to quantify pulmonary pressure and assess accompanying lesions

TREATMENT

CARDIOLOGY REFERRAL

  • Moderate to severe pulmonary hypertension

  • Moderate to severe regurgitation

  • Right heart failure

HOSPITALIZATION CRITERIA

  • Right heart failure

  • Planned surgery

  • Suspected endocarditis

MEDICATIONS
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