Pulmonic Regurgitation

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